TIGHTENING TOBACCO CONTROL LEGISLATION IN MALTA: A NATIONAL HEALTH PROMOTION INITIATIVE ON SMOKING 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 European Union 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 Passive smoking (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