Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
comprehensive strategies work best
- Christine Bundy (15 April 2005)
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Canada's progress in tobacco control
- Derek Yach (15 April 2005)
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The ground reality?
- Ms. Shefaly Yogendra (17 April 2005)
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comprehensive
- benjamin j dean (19 April 2005)
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Effective tobacco control policies
- Ediriweera B.R., Desapriya, Pike, I., Assistant Professor- Department of Pediatrics (6 May 2005)
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Tobacco use by youths in Canada is too high
- Ediriweera B.R., Desapriya, Pike I., Assistant Professor, Department of Pediatrics (6 May 2005)
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Re: comprehensive strategies work best
- Milton A. Mesa (6 May 2005)
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Christine Bundy, Senior Lecturer in Psychological Medicine/Health Psychology University of Manchester, Medical School
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Yach, McKee and Lopez, (BMJ 2005; 330: 898-900) provide a well formulated strategy for achieving behaviour change among people at high risk for developing lifestyle disease but only at the population level. For a strategy to work effectively it must consider all levels at which behaviour(s) can be controlled. Most health professionals work at the level of the individual and how to change individual behaviour and appropriately encourage and support patients to take responsibility for their health is very important clinical issue. Information is a necessary but not sufficient condition for behaviour change; health professionals need evidence and subsequent systematic training as to which strategies are more likely to work with which individuals. Insufficient financial support has been given to first class research studies on these individual strategies and this must be rectified if we are to have a truly comprehensive strategy for addressing behaviour change from the population to the individual. Competing interests: None declared |
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Derek Yach, Professor of Public health Yale, New Haven, CT 06520, USA
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In our article we refer to the need to find ways of speeding up the rate of decline in smoking. We mention that some countries have achieved rates of decline of 2 percent per year and others up to 6 percent. The latest data from Health Canada indicates that from 1983 to 2004 they achieved an average decline of 4.1% per year or a cumulative decline of 60% over 20 years. This is probably one of the largest such declines over a 2 decade period recorded and indicates how important it is to sustain and enhance tobacco control over a long time period. There is a need to add new tobacco control measures to our current list that would double this rate. Competing interests: As in the article. |
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Ms. Shefaly Yogendra, Doctoral Scholar, University of Cambridge Cambridge, UK
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The article highlights valuable lessons that can be transposed to handling other public health crises. But in the case of tobacco control itself, the lessons may fall short of expectations even as over 80% of smokers are in developing countries. These countries are also the 'growth markets' for tobacco vending multinationals. Several of these countries do not have well-developed or accessible health care systems. In many, the requisite infrastructure to enforce and monitor control measures may simply not be adequate. Further significant percentages of daily wages may be being squandered on buying tobacco products, with market skimming/ loss-leading low prices having been outdated by the customer's dependence upon - and hence need for - tobacco. We probably now need urgently a joined-up policy approach that doesn't leave the healthcare sector to pick up the pieces of an avoidable problem. Competing interests: None declared |
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benjamin j dean, dr oxford
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The article by Yach, McKee and Lopez, (BMJ 2005; 330: 898-900)made a very good point that 'individual responsibility can have its full effect only in a society where governments, private interests, and other sectors work together to support individuals making healthy choices.' I then read the letter by Christine Bundy who is of the opinion that comprehensive strategies work best and that behaviour must be addressed at the level of the individual as well as at the population level. She therefore believes that health professionals is key and that more financial investment is needed to determine what strategies work at this level. I believe that the main article has already argued that the macro policies make the difference to population behaviour and that efforts at the level of the individual are futile if society's 'powers that be' are not cooperating. This has been demonstrated in the history of controlling tobacco smoking. It is also demonstrated by the generally poor record of any medical/psychological interventions as far as controlling human behaviour is concerned. This can be seen in the evidence behind various smoking cessation adjuncts. Therefore it is essential that if we are to combat poor diet and physical inactivity in modern society, then we must learn from history and see that the most effective way to do this is by concentrating our effort on policies at the macro level. This will involve a positive interaction with the food industry, much advocacy and political acumen as the authors say. However I have to disagree strongly with the opinion that it is important to place emphasis on tackling obesity in primary care at the level of the individual. It is ineffective and inefficient tackling the problem in this manner, we must learn from history in this case. Competing interests: None declared |
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Ediriweera B.R., Desapriya, Research Associate- Department of Pediatrics,BC Injury Research and Prevention- University of British Columbia-V6H 3V4, Pike, I., Assistant Professor- Department of Pediatrics
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The Cochrane Collaboration reviews on a wide variety of clinical and public health topics. These reports provide assessments of the effectiveness of interventions based on a systematic review.(1) Various reports on effectiveness of tobacco control strategies are shown in the following ares: Screening patients for tobacco use, delivering brief advice or more intense or frequent counseling to quit, and the use of pharmacologic treatments (nicotine replacement therapy (NRT) or bupropion as first-line therapies) were identified as effective in increasing patient tobacco use cessation. The assessments of community interventions to reduce exposure to enviornmental tobacco smoke (ETS), reduce tobacco use initiation, and increase tobacco use cessation were also consistent. The evidence reviews of interventions to reduce tobacco use initiation in children and adolescents uniformly agreed on the effectiveness of increasing the unit price of tobacco products. Evidence reviews of interventions to increase tobacco use cessation uniformly documented the effectiveness both of increasing the unit price of tobacco products and of mass media campaigns (when implemented with other interventions). Telephone cessation support, when implemented with other interventions, was also identified as effective in increasing tobacco use cessation. Longitudinal studies consistently suggest that exposure to tobacco advertising and promotion is associated with the likelihood that adolescents will start to smoke.(2) Carefully planned and resourced, multicomponent strategies effectively reduced smoking within public places.(3) A recent systematic review in BMJ shows that smoke-free workplaces not only protect non- smokers from the dangers of passive smoking, they also encourage smokers to quit or to reduce consumption.(4) High intensity behavioral interventions that include at least one month of follow-up contact are effective in promoting smoking cessation in hospitalized patients. The findings of the review were compatible with research in other settings showing that NRT increases quit rates.(5) All of the commercially available forms of NRT (gum, transdermal patch, nasal spray, inhaler and sublingual tablets/lozenges) are effective as part of a strategy to promote smoking cessation. They increase the odds of quitting approximately 1.5 to 2 fold regardless of setting.(6) The results indicate the potential benefits of smoking cessation advice and/or counseling given by nurses to patients, with reasonable evidence that interventions can be effective.(7) REFERENCES: (1). The Cochrane Collaboration. . The Cochrane Database of Systematic Reviews. http://www.updateusa.com (2). Lovato C., Linn G., Stead L.F., Best A. Impact of tobacco advertising and promotion on increasing adolescent smoking behaviours. The Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003439. DOI: 10.1002/14651858.CD003439. (3). Serra C., Cabezas C., Bonfill X., Pladevall-Vila M., Interventions for preventing tobacco smoking in public places. The Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD001294. DOI: 10.1002/14651858.CD001294. (4). Fichtenberg, C.M., Glantz, S.A., Effect of smoke-free workplaces on smoking behavior: systematic review. BMJ 2002; 325:188 (5). Rigotti N.A., Munafo M.R., Murphy M.F.G., Stead L.F., Interventions for smoking cessation in hospitalised patients. The Cochrane Database of Systematic Reviews 2002, Issue 4. Art. No.: CD001837. DOI: 10.1002/14651858.CD001837. (6). Silagy C., Lancaster T., Stead L., Mant D., Fowler G., Nicotine replacement therapy for smoking cessation. The Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD000146.pub2. DOI: 10.1002/14651858.CD000146.pub2. (7).Rice V.H., Stead L.F., Nursing interventions for smoking cessation. The Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD001188.pub2. DOI: 10.1002/14651858.CD001188.pub2. Competing interests: None declared |
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Ediriweera B.R., Desapriya, Research Associate Department of Pediatrics,BC Injury Research and Prevention- University of British Columbia-V6H 3V4, Pike I., Assistant Professor, Department of Pediatrics
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Currently 45, 000 Canadians die of smoking-related causes each year, and despite all efforts at reduction, more than one-fifth of all Canadians smoke. (1) Many people start smoking in their adolescent years. In fact, recent statistics show that of all adult smokers, 85 percent began before the age of 18. (1) Although Canadian federal laws make it illegal for people under the age of 18 to buy cigarettes, 22 percent of Canadians aged 15-19 smoke. (2) Therefore, it is important that all best practices in smoking prevention should be directed at youths and young adults in Canada. (1). Health Canada. Smoking in Canada; An overview. 2001. Ottawa. (Canadian Tobacco use Monitoring Survey). (2). Health Canada. Smoking in Canada; An overview. 2003. Ottawa. (Canadian Tobacco use Monitoring Survey). Competing interests: None declared |
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Milton A. Mesa, Assistant Professor, Health Promotion - Global Health Department of Public Health, AIIAS, Philippines - U. Adv. del Plata, School of Medicine, Argentina
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In their article, Yach, McKee and Lopez, (BMJ 2005; 330: 898-900) draw our attention to important lessons learned through the years from the history of tobacco control. From a developing country perspective I find that lessons 3, 4 and 7 are a key in addressing the risk factors of unhealthy diets and lack of physical activity. Public Health decisions at policy level usually take longer in our context compared to developed countries. Waiting for detailed evidence of the effectiveness of interventions to start discussing the possibility of taking decisions at policy level will certainly deprive our population from easier–healthier choices. There are specific interventions known to be effective. Lobby is needed at regional and national level to provide a favorable context for the implementation of these interventions. In some cases is more effective to move from regional level to national level than expecting a national action to start acting. I personally believe that “broad based, well networked, vertical and horizontal coalitions” might be one of the most significant lessons for our developing countries. Funds allocated for prevention are usually not prioritized. Policy will provide a favorable context, but hands at work are needed. From personal experience in Argentina and the Philippines (DEMOBAL Project, Program for Prevention of Infarction in Argentina, Preventive Medicine, 2001, 33: S14) this kind of network will provide the human resources and sometimes part of the material-financial resources needed for planning, implementation and evaluation of interventions. Motivated health professionals and community members often motivate policy makers. Financial support from government or external funds are much needed to increase the probabilities of success, but decision for allocating these funds usually do not take place without a story of sacrifice and dedication from a committed group of community members and health professionals. Quoting Dr. Peka Puska (International Journal of Epidemiology, 2001; 30: 1493-1494) “The global problem is huge: Much firm evidence exists for prevention. It is time to act –with sound theoretical base and sufficient preventive dose- from demonstration to national policy actions –not exporting, but working in global partnership- and also putting one’s heart into the action!” Competing interests: None declared |
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