TIGHTENING TOBACCO CONTROL LEGISLATION IN : A NATIONAL HEALTH PROMOTION INITIATIVE ON M. R. SAMMUT SENIOR MEDICAL OFFICER IN PRIMARY HEALTH CARE

ABSTRACT INTRODUCTION

Introduction: In Malta, The Ottawa Charter for Health therefore should target an issue individual smokers, doctors and Promotion describes health that has an appreciable effect the adult general public are promotion as "the process of on health. recognising the ill effects of enabling people to increase smoking, and are seeking to do control over, and to improve, Smoking is such an issue. stng adults and, more their health"l. It consists of the The World Health Organisation importantly, to trigger off a similar reduction among adolescents, informed application of any has stated: "Tobacco products with a consequent protection combination of interventions have no safe level of against disease and death. (educational, legal, fiscal, consumption. They are the only economic, environmental and legal consumer products that Method: Local initiatives organisational) designed to cause ill health and premature against smoking were compared facilitate the achievement of death when used exactly as the to the WHO - World Health health and the prevention of manufacturer intends. Unless Organisation's Ten-Point disease. Health promotion can concerted action is taken Programme for Successful To­ work at three levels: at the quickly, 250 million of today's bacco Control, to a WHO model primary level to prevent illness children will die prematurely law for comprehensive tobacco or maintain health; at the from an avoidable cause - control, and to directives and resolutions. secondary level to stop or tobacco use."4 In Malta smoking reverse the process of illness; is considered as the foremost Results: While procedures and at the tertiary level to prevent preventable cause of premature 5 involving health education, long-term sequelae or death and disease • 2 smoking cessation, prof­ ameliorate the effects of illness • essionals' smoke-free example, Process and fiscal policies are all being After undertaking an implemented, Maltese tobacco assessment of needs in respect A comprehensive ass ­ control laws and regulations are ill' of tobacco and health in Malta, essment will include ascertaining still deficient. -- this initiative goes on to set the views of the professionals appropriate aims and objectives. Conclusion: A health prom­ and the needs of the general otion strategy of tightening Strategies of intervention are public and the individual smoker. tobacco control legislation needs then recommended, followed by to be introduced in Malta methods of evaluation and The professionals' view forthwith. This includes strict feedback. The role of health-care enforcement, more severe personnel is important in setting penalties, banning of sales to NEEDS ASSESSMENT a non-smoking example to the adolescents and in places public in general and their frequented by them , the Purpose patients in particular. While in prohibition of smoking in 1989 25% of Maltese doctors enclosed public places, a total smoked6 , preliminary results of ban on advertising and A need is something people a 1999 survey of members of sponsorship, and the introduction could benefit from. Just as a the Medical Association of Malta of maximum tar-yield levels and doctor systematically assesses revealed that this percentage has conspicuous and effective health the needs of a patient before dropped to 13% (unpublished warnings on all tobacco products. prescribing the effective data). A study carried out in An overall priority is the setting­ treatment, the optimal utilisation up of a coordinating tobacco 2000 for EUROPREV (European o f the resources of health control authority to effectively Network for Prevention and services (including health manage all efforts to stem the Health Promotion in Family promotion) depends on a tobacco epidemic. Medicine and General Practice) systematic assessment of the showed that 12% of family Keywords: Tobacco control, healthcare needs of the 3 doctors in Malta smoke legislation, Malta , health population . Any worthwhile cigarettes while 3% smoke cigars promotion. health promotion initiative or the pipe (unpublished data).

JUNE 2002 7 the family physician / it-tabib tal-familja The general public (en - healthier after quitting. This According to World Health vironmental tobacco smoke - cohort of smokers also Organisation figures, in the ETS) is an established cause of expressed a strong desire to quit, early-to-mid 1990s 42% of males disease and death. The harmful as shown by the results that and 24% of females in devel­ effects include asthma, middle about nine out of ten believed in oped countries smoked, while in ear infection and bronchitis or quitting with help and had tried developing countries the corre­ pneumonia in children, heart quitting more than once. Over sponding percentages were 48% disease and lung cancer13. half thought they would not be and 7% respectively7. The mor­ Researchers from the University smoking a year later17. bidity and mortality effects of of Minnesota Cancer Center smoking are well known. Ac­ reported a derivative of a Conclusion ofneeds assessment cording to WHO estimates, there tobacco-specific lung car­ It may therefore be said that are currently 4 million deaths a cinogen (NNK) found in the urine individual smokers, doctors and year from tobacco, a figure ex­ of non-smokers exposed to ETS the adult general public are pected to rise to about 10 mil­ under real-life conditions, recognising the ill effects of lion by the 2020s or early 2030s. reportedly the first hard evidence smoking, and are seeking to do By that date, based on current of how passive smoking can something about it. This is smoking trends, tobacco is pre­ cause cancer (214th National however not the case with dicted to be the leading cause of Meeting and Exposition of the adolescents, where smoking in disease burden in the world, American Chemical Society, Las 1998 remained at the same level causing about one in eight Vegas, Nevada, USA, Sept. 7- it had been eight years deaths. Seventy per cent of those 11, 1997). A comprehensive previously. There is an evident deaths will occur in developing meta-analysis of ten cohort and need for a health promotion countries8. eight case-control studies has initiative on smoking to concluded that exposure to ETS accelerate the reduction in In Malta, while 54% of 25-64 in the home or workplace smoking among adults and, year old men and 20% of women increases a person's risk of more importantly, to trigger off (of the same age) smoked in the coronary heart disease by about a similar reduction in smoking mid-1980s9, in 1995 this per­ 25%14. A phone-in survey carried among adolescents. centage for men dropped to 38% out in Malta indicated that 77% with that for women only mar­ of callers to a popular local ginally decreasing to 17%10. television programme were SETTING AIM AND OBJEC­ Among Maltese adolescents too, against smoking in public TIVES cigarette smoking is common: places15 . EvenMalta'smembers 31 % of the 20,815 schoolchil­ of parliament have designated Aim dren aged 11-16 who took part all indoor areas of the House of in a Caritas/Pride/DISCERN Representatives in the The aim of this initiative is Survey stated that they had Presidential Palace, Valletta as the improvement of the health smoked at least one cigarette in smoke-free zones (apart from status of the Maltese population 199011 . A follow-up survey in specially designated areas) 16. in general (primary prevention) 1998 of a sample size of 1,100 This shows that the majority of and of smokers in particular schoolchildren showed that ciga­ the Maltese population have (secondary and tertiary rette use was still high at 32%12. come to appreciate such dangers prevention) . of ETS. The WHO calculates that Objectives smoking causes 90% of cancer The individual smoker of the trachea, bronchus and In a study of the smoking habits lung, 75% of chronic bronchitis of applicants for smoking In chapter 27 (entitled 'To­ and emphysema, and 25% of cessation clinics in Malta, it was bacco Use' ) of 'Healthy People ischaemic heart disease. Apply­ found that: 2010', the United States' health ing these percentages to local goals for this decade, no less reported deaths from these dis­ • 38% smoked all the time and than 21 objectives are enumer­ eases, the number of yearly everywhere, ated regarding tobacco use 18 deaths in Malta attributable to • 15% when nervous, upset or alone , while the WHO docu­ smoking had risen by 28% from angry, ment Health21 lists 21 general 19 289 in 1987 to 371 in 1999, i.e. • 12% with or after food or objectives . On the other hand, one death every day (Agius drink, and the UK Department of Health's Muscat, H., personal communi­ • 9% at work. 'Saving Lives: Our Healthier cation). Nation' rejects "the previous Seventy-two per cent of smokers Government's scattergun tar­ thought they would be much gets" and limits its objectives to

JUNE 2002 8 the family physician / it-tabib tallamilja priority areas, setting "tougher organised by the Health DEFINING THE STRATEGY but attainable targets"20. This is Promotion Department. precisely what this strategy plans From the WHO Ten-Point to do. The second objective is based Programme for Successful on the targets set by the UK Tobacco Control4 (see Table 1), 20 While the chance of getting a Department of Health and point 4 emphasises the myocardial infarction is halved comprises: importance of health education, 24 hours after stopping smok­ smoking cessation and the ing (British Medical Association smoke-free example of Annual Scientific Meeting in Objective 2: The reduction of healthcare professionals. This Malta, 22-26 September 1992), mortality rates from smoking­ point is being actively pursued according to a U.S. Surgeon related diseases: by the Health Promotion General Report the added risk of • respiratory cancer in people Department through a number disease suffered by smokers is under 75 years by 20% over of educational and other reduced by a half or more within 15 years; activities, amongst which the one year of quitting, and then • chronic bronchitis and em­ organisation of smoking 17 declines more slowly to reach physema in people under cessation clinics since 1991 • the risk of a never-smoker after 75 years by 30% over 15 As regards smoke-free example, some years21. A recent UK study years; the needs assessment (above) in fact concluded that quitting • coronary heart disease in has shown a drop by one-half in smoking before middle age people under 75 years by the smoking rate among doctors avoids more than 90% ofthe risk 40% over 15 years. over the past ten years. attributable to tobacc022 . The other nine points of the Therefore, based on recent Yearly mortality rates of the programme refer to public policy French experience following the above diseases are a direct issues. Points 2, 3 & 9 concern introduction of tough tobacco measure of this objective and the use of fiscal policies to 23 control legislation , the first may be obtained from the discourage the use of tobacco, objective of this initiative is: National Mortality Register kept oftobacco taxes to finance other at the Malta Department of tobacco control measures, and Health Information. of economic alternatives to Objective 1: The reduction tobacco growing and of the number of smokers in manufacturing. While the last of the general population by 15% over 5 years. W.H.O. TEN-POINT PROGRAMME FOR SOCCESSFOL TOBACCO CONTROL The measures proposed for 1. Protection for children from becoming addicted to tobacco. this objective include: 2. Use of fiscal policies to discourage the use of tobacco, such as tobacco taxes that increase faster than the growth in prices and income. Direct Measures: • Population survey through the 3. Use a portion of the money raised from tobacco taxes to finance other national census (next due in tobacco control and health promotion measures. 2005); 4. Health promotion, health education and smoking cessation programmes. • Targeted surveys, such as Health workers and institutions set an example by being smoke-free. repetitions of those of 5. Protection from involuntary exposure to environmental tobacco smoke adolescents carried out (ETS). previouslyll. 12. 6 . Elimination of socioeconomic, behavioural and other incentives which maintain and promote use of tobacco. Proxy Measures: ! 7. Elimination of direct and indirect tobacco advertising, promotion and • Sales of tobacco (taking sales I sponsorship. to the tourist population as a constant factor); 8. Controls on tobacco products, including prominent health warnings on • Sales of smoking-cessation tobacco products and any remaining advertisements; limits on and pharmaceuticals; mandatory reporting of toxic constituents in tobacco products and tobacco smoke. • Applications for smoking cessation clinics organised by 9. Promotion of economic alternatives to tobacco growing and the Health Promotion manufacturing. Department of Malta; 10. Effective management, monitoring and evaluation of tobacco issues. • Participation rates in 'Quit & Win' campaigns, also Table 1: WHO Ten-Point Programme for Successful Tobacco Control4

JUNE 2002 9 the family physician / it-tabib tallamilja the three may not be so relevant necessary preparations are hazards of involuntary to Malta, tobacco taxes have made for political backing and exposure to tobacco been raised annually over recent public support26 , 27. While the smoke; and years. In fact, tax increases have tobacco industry advocates self­ (e) to regulate tobacco prod­ been shown to be the single most regulation, it is well known that ucts and the distribution of effective intervention to reduce the implementation of a tobacco these products in a way that demand for tobacc024 . A further control policy depends on legis­ is consistent with public step to be implemented is the lation that is comprehensive, health goals." channelling of part of such taxes closely monitored and strictly towards the funding of health enforced28 . As declared by Investigations by Joosens29 promotion and medical Simpson, "the evidence that to­ have concluded that a wide to­ research25 , and towards the bacco control policy cannot bacco control strategy, incor­ replacement of sponsorship of achieve maximum effectiveness porating advertising bans, is sports and cultural activities without legislation becomes needed to maintain the down­ currently supported by the more abundant every year"28. ward trends in consumption tobacco industry. shown to have followed a ban in tobacco advertising30 . The WHO The remaInIng six points of International experience and document Health21 states that, the WHO Programme concern evidence together with greater availabil­ legislation: the banning of sales Every country has to work ity of treatment products and to and advertising targeted at out a specific strategy that is cessation advice, the tighter children; protection from prepared taking into account in­ regulation of tobacco products involuntary exposure to ternational factors. Existing leg­ and a ban on the advertising and environmental tobacco smoke; islation in Malta was compared sponsorship of tobacco prod­ the elimination of socio­ to a model of legislation for com­ ucts will reduce the annual toll economic, behavioural and other prehensive tobacco control rec­ of up to 2 million deaths ex­ incentives which maintain and ommended by the World Health pected during the next 20 l9 promote the use of tobacco Organisation (Collishaw, N. E., years . The same document (including direct and indirect former Acting Chief, WHO To­ goes on to cite a case in point, tobacco advertising, promotion bacco or Health Unit, personal namely the Evin Law in France. and sponsorship); controls on communication). The purpose Five years after the introduction tobacco products, including of this model "is to provide a of this 1991 law (which banned prominent health warnings on legislative response to a national cigarette advertising, created tobacco products; and limits on public health problem of sub­ smoke-free public places and and mandatory reporting of toxic stantial and pressing concern increased prices), cigarette con­ constituents in tobacco products and, in particular, sumption in France had fallen and tobacco smoke. Effective by 16%23. Thus, effective legis­ management, monitoring and (a) to protect the health of the lation does seem to reduce to­ evaluation of these tobacco people in the light of bacco consumption. issues are essential. conclusive evidence implicating exposure to After comparing the local tobacco smoke in the Legislation in Malta: present and situation with international ex­ incidence of numerous proposed perience and evidence, it is evi­ debilitating and fatal Regarding local legislation on dent that local tobacco control diseases; smoking and young people, at laws and regulations are still de­ (b) to protect young persons present this simply bans the sell­ ficient, and this health promo­ and others, to the extent ing of tobacco to those under 16 tion initiative on smoking thus that is reasonable, from years of age. Besides voluntary proposes the tightening of such inducements to use tobacco measures against ETS taken in legislation as its strategy for products and consequent selected cases (Air Malta Euro­ Malta. dependence on them; pean flights , one guest-house, a (c) to enhance public aware­ handful of restaurants and some Health promotion approach & ness of the hazards of workplaces), smoking is pres­ practice-model tobacco use by ensuring the ently only banned in public trans­ Changes in tobacco use can effective communication of port, cinemas, theatres, hospi­ be brought about in the environ­ pertinent information to tals, clinics or other health insti­ ment and social structures us­ consumers of tobacco tutions, local television studio ing an authoritative/ collective products; broadcasts and schools. Adver­ model with a top-down and ex­ (d) to protect people to the tising is prohibited on television, pert-led approach, as long as extent that is reasonable radio (or other broadcasting and possible from the medium) and in cinemas, but

JUNE 2002 10 the f amily p hy sician / it-tabib tal-fami1ja the three may not be so relevant necessary preparations are hazards of involuntary to Malta, tobacco taxes have made for political backing and exposure to tobacco been raised annually over recent public support26 , 27. While the smoke; and years. In fact, tax increases have tobacco industry advocates self­ (e) to regulate tobacco prod­ been shown to be the single most regulation, it is well known that ucts and the distribution of effective intervention to reduce the implementation of a tobacco these products in a way that demand for tobacc024 . A further control policy depends on legis­ is consistent with public step to be implemented is the lation that is comprehensive, health goals." channelling of part of such taxes closely monitored and strictly towards the funding of health enforced28 . As declared by Investigations by Joosens29 promotion and medical Simpson, "the evidence that to­ have concluded that a wide to­ research25 , and towards the bacco control policy cannot bacco control strategy, incor­ replacement of sponsorship of achieve maximum effectiveness porating advertising bans, is sports and cultural activities without legislation becomes needed to maintain the down­ currently supported by the more abundant every year"28. ward trends in consumption tobacco industry. shown to have followed a ban in tobacco advertising30 . The WHO The remaInIng six points of International experience and document Health21 states that, the WHO Programme concern evidence together with greater availabil­ legislation: the banning of sales Every country has to work ity of treatment products and to and advertising targeted at out a specific strategy that is cessation advice, the tighter children; protection from prepared taking into account in­ regulation of tobacco products involuntary exposure to ternational factors. Existing leg­ and a ban on the advertising and environmental tobacco smoke; islation in Malta was compared sponsorship of tobacco prod­ the elimination of socio­ to a model of legislation for com­ ucts will reduce the annual toll economic, behavioural and other prehensive tobacco control rec­ of up to 2 million deaths ex­ incentives which maintain and ommended by the World Health pected during the next 20 l9 promote the use of tobacco Organisation (Collishaw, N. E., years . The same document (including direct and indirect former Acting Chief, WHO To­ goes on to cite a case in point, tobacco advertising, promotion bacco or Health Unit, personal namely the Evin Law in France. and sponsorship); controls on communication). The purpose Five years after the introduction tobacco products, including of this model "is to provide a of this 1991 law (which banned prominent health warnings on legislative response to a national cigarette advertising, created tobacco products; and limits on public health problem of sub­ smoke-free public places and and mandatory reporting of toxic stantial and pressing concern increased prices), cigarette con­ constituents in tobacco products and, in particular, sumption in France had fallen and tobacco smoke. Effective by 16%23. Thus, effective legis­ management, monitoring and (a) to protect the health of the lation does seem to reduce to­ evaluation of these tobacco people in the light of bacco consumption. issues are essential. conclusive evidence implicating exposure to After comparing the local tobacco smoke in the Legislation in Malta: present and situation with international ex­ incidence of numerous proposed perience and evidence, it is evi­ debilitating and fatal Regarding local legislation on dent that local tobacco control diseases; smoking and young people, at laws and regulations are still de­ (b) to protect young persons present this simply bans the sell­ ficient, and this health promo­ and others, to the extent ing of tobacco to those under 16 tion initiative on smoking thus that is reasonable, from years of age. Besides voluntary proposes the tightening of such inducements to use tobacco measures against ETS taken in legislation as its strategy for products and consequent selected cases (Air Malta Euro­ Malta. dependence on them; pean flights , one guest-house, a (c) to enhance public aware­ handful of restaurants and some Health promotion approach & ness of the hazards of workplaces), smoking is pres­ practice-model tobacco use by ensuring the ently only banned in public trans­ Changes in tobacco use can effective communication of port, cinemas, theatres, hospi­ be brought about in the environ­ pertinent information to tals, clinics or other health insti­ ment and social structures us­ consumers of tobacco tutions, local television studio ing an authoritative/ collective products; broadcasts and schools. Adver­ model with a top-down and ex­ (d) to protect people to the tising is prohibited on television, pert-led approach, as long as extent that is reasonable radio (or other broadcasting and possible from the medium) and in cinemas, but

JUNE 2002 10 the f amily p hy sician / it-tabib tal-fami1ja there are no controls on spon­ people are received or spot checks for tar levels in sorship by tobacco companies housed, where higher cigarettes (in addition to tests (with a prominent tobacco brand education and vocational routinely done by the local in fact sponsoring the local pre­ training are given, in radio or tobacco industry). The mier football league). Health TV studios open to the public, government would also need to warnings are inconspicuous and where exhibitions are held, monitor the proper enforcement ineffective, being confined to where sports are practised, of legislation, which always costs cigarette packets on one side and in enclosed premises of money. Other expenses would only. However, the main prob­ ports and airports33 . of course be incurred by lem is the lack of enforcement of 5. Tobacco advertising enclosed public establishments these laws and regulations31 , 32 . regulations to implement a in setting up specific smoking total ban of advertising except rooms, and by tobacco As such, the following are the at point of sale (with a one­ companies in altering health main components of the strat­ year delay in respect of the warnings on tobacco products. egy proposed to tighten local press), and of sponsorship The Maltese government can rest legislation, based on the WHO (after a two-year delay) and assured that a comprehensive model tobacco law (cited above) other forms of tobacco tobacco control policy is not and European Union (EU) di­ promotion (including free likely to harm the economy24 . rectives and resolutions (in the samples, discounts, gifts and light of Malta's present negotia­ contests) , and to prohibit the As such, besides the expected tions to join the EU): use of tobacco trademarks opposition of the tobacco on non-tobacco goods34 . In industry to any measures that 1. Enforcement regulations to spite of the directive referred would affect their sales, it is designate health inspectors, to here being annulled during envisaged that there would be police officers and local a landmark case in the no difficulties regarding the wardens as being responsible European Court of Justice in feasibility and viability of such to enforce tobacco Luxembourg during October legislative strategy against legislation. 2000, the European smoking. 2. The updating of tobacco Commission is to press ahead legislation to make the with legislation to phase out breaking of such legislation tobacco advertising and EVALUATION & FEEDBACK liable to more severe sponsorship inside the E.U.35 penalties (and serve as a 6. The introduction of Point 10 of the WHO Ten­ deterrent) . conspicuous and effective Point Programme for Successful 3. Sales legislation to be revised health warnings on the front, Tobacco Control emphasises the so as to protect the young back and one side of cigarette importance of effective through enforcing the ban of packets, and the extension of management, monitoring and single cigarettes, and by such warnings to all forms of evaluation of tobacco issues4. 36 prohibiting the sale oftobacco tobacc0 , 37 Moreover, Evaluation is essential to products in schools, colleges, maximum tar-yield appraise the success (or failure) universities, and sports or regulations are required to of an intervention, so that the athletic facilities (amongst reduce the health damage necessary feedback is available 38 others). Sales through caused by tar in cigarettes . for the planning process. automated vending machines, using self-service Process displays, by mail order or the Time frame, financial Internet, and to persons less requirements, feasibility and Both the process and the impact/ than 18 years (presently viability outcome are evaluated. Process under 16) would also be The time frame for the evaluation assesses the banned. implementation of such implementation of the strategy, 4. Regulations banning smoking legislation must conform with in this case the tightening of in enclosed public places the schedule imposed on the local tobacco control legislation. (with the exception of country by its negotiations for This can be performed prior to designated no-smoking accession to the European the actual coming-into-force of rooms) to extend the present Union. the legislation by initially limited ban. These would publishing it as a white paper to come to include establish­ A specific financial require­ enable comments from ments where services are ment incurred by the interested parties and the provided to the public, where government would be the general public. The process can elderly persons are received, arrangement with a specialised also be evaluated after the where children or young overseas laboratory to perform

JUNE 2002 1 1 the family physician / it-tabib tal-Jamilja strategy is initiated through necessary strategic initiatives. declared by Sir George Young, a qualitative techniques including The tightening of tobacco legis­ British health minister who observations, interviews and lation is a prime example of understood the politics of case studies. health promotion not being the tobacco: "The solution to many responsibility of just the health of today's medical problems will Impact and Outcome sector, but of going "beyond not be found in the research lifestyles to well- being", as the departments of our hospitals, but Impact evaluation assesses Ottawa Charter for Health Pro­ in Parliament. For the the immediate effect of a health motion concludes 1. prospective patient, the answer promotion strategy, while may not be incision at the evaluation of the outcome is Thus, tobacco control must operating table, but prevention concerned with the long-term be not merely a top public health by decision at the cabinet consequences. As legislative priority, but a top public policy table."28 action uses the authoritative priority with the government model for social change, the playing a central and crucial It is augured that the Maltese 4 latter will only occur after a role . Among the resolutions government will heed these wise number of years have passed, approved at the conclusion of words through supporting and therefore permitting only the the 11 th World Conference on implementing the development, long-term outcome to be Tobacco or Health in Chicago, monitoring and evaluation of measured here. One must keep U.S.A. during August 2000, was national health promotion in mind that evaluation may be the recommendation that all policies in general, and this influenced by difficulties in national health ministries have initiative on smoking in measurement, attribution, full-time staff charged with particular. contamination and proliferation overall responsibility for of the process. In this case, ensuring sustained tobacco 39 knowledge, attitudes and quality control programmes . ACKNOWLEDGEMENTS of life are difficult to measure, Members of the U.K. House of and so outcome evaluation Commons health committee The author wishes to thank should be based more on have also recommended the Dr Gauden Galea and Dr Harley assessment of the following creation of a tobacco regulatory J Stanton, both of the WHO direct measures: authority4o. In fact, the setting­ Western Pacific Regional Office, up of a coordinating tobacco for their helpful review of this • behaviour: population and control authority has been paper. target surveys of smoking emphasised as a priority for status; Malta. Such authority must be • health status: of smoking­ given the mandate to manage REFERENCES related diseases; all efforts required to stem the • mortality: from smoking­ tobacco epidemic, not least the 1. World Health Organisation. related diseases. coordination of the different Ottawa Charter for Health activities existing today to avoid Promotion. First International However, to assess the short­ duplication and increase Conference on Health 41 term impact, easy-to-measure effectiveness . Promotion, Ottawa, 21 performance indicators can also November 1986. WHO/HPR/ be used as proxy measures: Malta was one of the HEP/95.1. Website: http:// signatories of the 2002 Warsaw www.who.int/hpr/docs/ • sales of tobacco and Declaration for a Tobacco-free ottawa.html - accessed on smoking-cessation , which committed 19th March 2000. pharmaceuticals; participating countries to the • participation rates in 'Quit & effective implementation of 2. Tones, K., Tilford, S., Win' campaigns and comprehensive policies with Robinson, Y. Health applications for smoking measurable impact on the Education. Effectiveness and 42 cessation clinics. reduction of tobacco use . efficiency. Chapman & Hall, These include high taxes, bans London, 1990. on tobacco advertising, CONCLUSION sponsorship and promotion, 3. Wright J, Williams R, protection against involuntary Wilkinson J R. Development exposure to environmental and importance of health Health promotion can be at­ tobacco smoke in public places needs assessment. BMJ tained only by the assessment and workplaces, access to 1998: 316:1310-1313. of health needs, and their sub­ cessation measures and strict sequent satisfaction through the control on smuggling. As

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