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Report of Proceedings 7th Annual Business Meeting of the Tobacco-free Healthy Cities MCAPVejle County, Denmark Vejle Center Hotel, Willy Sørensens Plads 3, VEJLE 29, 30 September - 1 October 1997 Special thanks to the Vejle County, to the Lord Mayor of Vejle and all the staff for the Non Smoking County Project of Vejle for their hospitality and efficiency in hosting the meeting and the Seminar that followed. Elizabeth Tamang
The Non Smoking County project manager and staff of Vejle welcomed all participants to the city of Vejle. This was the first time a Tobacco MCAP business meeting was being held in a city that was actually not a member of the Tobacco MCAP Network. But in our last business meeting in Kaunas it had been agreed to host the meeting in Vejle as a sign of our collaboration with other European projects. The Tobacco MCAP members had also been generously invited to participate to the international seminar organised as part of the Non Smoking County project. The purpose of the meeting was to welcome the new cities who had joined the MCAP and to establish a plan of action for the coming year as well as exchange and share experiences with the Non Smoking County project and member cities. A general presentation of all the participants took place. Cities participating at the meeting were Geneva, Lodz, Torun, Gdansk, Ferrara and Dublin. A representative of the Tobacco MCAP co-ordinating centre was also present. Lisbeth Peterson was appointed to chair the meeting and Elizabeth Tamang as the rapporteur A Tobacco-free Europe Dr. Peter Anderson after welcoming all participants, started by saying that there are 870 million people in Europe distributed in 51 countries. There are few single things that can be done which have a dramatic impact on improving people's lives. Action on tobacco is one of them. During a short presentation of twenty minutes tobacco will have resulted in 50 deaths in the European Region and cost the Region four million dollars. A reduction in tobacco use is the single most important action that countries and cities can take for both health and economic gain. Cigarettes are the most commonly used drug in the European Region. Thirty six percent of adults are daily smokers. There is a whole lot to do but we have got to act. This represents our challenge. We can help prevent a whole new generation of women and young people becoming addicted to cigarettes. We can help 180 million smokers to quit. Tobacco is the most dangerous drug commonly used in our Region and cities. One half of all people who regularly smoke die from their habit. Every hour, 140 people are killed by tobacco. This is the same as 25 plane crashes every day. And it is going to grow worse. Unless we help current smokers to quit, in twenty years time, tobacco will be responsible for 2 million deaths a year, one in five of all deaths. We can prevent many of these deaths. At any age, there are benefits to quitting. If smokers quit before the age of 40 years they will live nearly as long as non-smokers. Maybe these deaths do not matter. We have all got to die sometime. But, they do. What about the ill health, pain and suffering caused by tobacco? What about the loved ones left behind? What about enforced smoke? Up to ten percent of all tobacco related deaths result from breathing other people's smoke. What about economic development? In the Eastern European countries, one in five of all 35 year old men will be killed by tobacco before they retire. This is twice as high as in western Europe and a hugewaste of human and economic resources. In the European Region 80 billion cigarettes are exported to Russia by the United States. Maybe this is the price to pay for the economic benefits from tobacco. This is what the tobacco industry says. But this is false. On balance, there are no economic benefits from tobacco, only losses. The World Bank has calculated that adding up all the benefits and costs, the world tobacco produces an annual global loss of 200 billion dollars. In all countries and cities tobacco use is bad news for the economy. In contrast, tobacco control policies are a cost-effective way to save lives and benefit the economy. We have failed to obtain effective political support for tobacco control policies. It was in the 1960s that the Royal College of Physicians of London and the first United States Surgeon General's report on Smoking and Health were published. Both reports called for tough action against smoking. But public health failed. We have failed to inform the public adequately on tobacco issues and to get popular support and cultural change for action. The tobacco industry is rather good at advertising its cause. We need to be better and to be bold in our advertisement, like the one "Bob, I've got emphysema!" Even smokers give support to tobacco control policies. Most smokers want to quit smoking and support smoke- free public places. We have allowed the public to be deceived by the tobacco industry. For too long, the industry has lied to the public about its knowledge of the harms done by tobacco and the addictive nature of nicotine. In the 1960s the industry wrote, "We are in the business of selling nicotine, an addictive drug." In the 1970s, the industry knew that "In most cases, the smoker of a filter cigarette gets as much or more nicotine and tar as from a regular cigarette". It is for these and other reasons that the Food and Drug Administration of the United States acquired jurisdiction over cigarettes. Similar moves should be undertaken in Europe. It is also clear that the tobacco industry targets young people. We say that we should protect our children. But why should children take notice of school programmes, when the outside world proposes a different reality. The reality is that in all our cities over one third of our adults smoke. The reality is that there is widespread marketing of cigarettes. If we really want to protect our young, all forms of advertising and sponsorship should be banned. The 10th World Conference on Tobacco or Health in Beijing gave strong support for the international framework Convention for tobacco control. The third Action Plan for a Tobacco free Europe proposes to establish a Tobacco Control Commission for Europe by 1 January 1999. It is therefore time for all of us to take a stand and say things that may not be popular. During the next decade, more than twelve million men and women will die an agonizing death from diseases caused by smoking, leaving in their wake countless family tragedies and great economic loss to our societies. Unless we take strong action, future generations will condemn us for failure to control one of the worst problems facing our people.
Tuesday 30 September Overview of the Tobacco-free Healthy Cities MCAP As representative of the co-ordinating centre for the Tobacco MCAP Elizabeth Tamang gave a brief overview. Starting with the history of the project of how in 1990 seven cities interested in developing models of good practice in reducing tobacco use framed an MCAP on Tobacco-free Cities. They took advantage of the major initiative of the WHO Regional Office for Europe: the Action Plan for a Tobacco free Europe. The founding cities with the WHO/EURO office were Belfast, Dublin, Frankfurt, Glasgow, Gothenburg, Kaunas and Stockholm. At the first meeting five key themes for intervention were identified: children, economic issues, local government, public places and health services. Belfast agreed to become the co-ordinating city for the MCAP on tobacco and hosted the first business meeting which concentrated on the five key themes and added a further one: adults in the community. Each year the MCAP cities meet to report on activities and exchange information and to set up new plan of action. The second business meeting in 1992 was hosted by Frankfurt, followed by Pécs in 1993, Padova in 1994, Bologna in 1995 and Kaunas in 1996. A survey was carried out in 1995 to see the activities that are being carried out and the different situations in the different member cities. The Network has published "Working for Tobacco-free Cities" Smoke-free Europe series no.11 which also has an Italian version called "Verso le città sane" and "Keep Kids smoke-free" cards. A Newsletter is also produced twice a year. During the last business meeting in Kaunas it was decided to relaunch the Tobacco MCAP Network together with the third Action Plan for a Tobacco-free Europe for the 1997-2001 period. A letter was to be sent to all core Healthy Cities Project and existing tobacco, alcohol and drug MCAP cities inviting them to join the next phase of the Tobacco MCAP. To be able to join the Network all cities were to:
Group discussion The overview was followed by a session of reporting from the participating cities. Then a very active discussion took place where the future plan of action for 1998/99 was also discussed. Every body recognised the importance of intersectoral collaboration for our tobacco control activities. It is also important to be able to mobilise cities as a broad European movement so that there is added value to our actions.It was agreed that all cities should have a City Action Plan for tobacco control which should be endorsed by the Healthy Cities. The City Action Plan should:
The MCAP members would like to have:
Wednesday 1 October A proposal was made that member cities should incorporate tobacco into the City Tourist Guide. Each city could also consider producing their own guide to smoke-free restaurants. It was important to identify a universal symbol to sign post smoke free areas. This activity could be promoted by WHO/EURO in all cities identifying this as a European Movement.A conference of Lord Mayors of all the Healthy Cities including the national networks was also considered as a possible future European movement. Individual behaviour is connected with community changes. Cities can decide to confront objective problems or relative problems through health promotion or problem prevention. Action research aims at producing innovations. It makes research part of a process and builds communication networks between different actors of community life and institutions like the local elite, cultural life, media, voluntary organisations, welfare services, neighbourhoods, homes, local administration and politics. An action research project should have elements like policy thinking, service, include brief interventions in primary health care, educational events, youth work, involve families and inspire new networks. Working Session All participants were easily divided into three working groups, considering they had been playing bowling as three teams the evening before. Each group had to consider on a strategy on how to mobilise and evaluate groups of people for tobacco control activities. Group one had to tackle local key persons, group two the media and group three the public and people. Results of the working groups are included in annex 1. Conclusions The proceedings of the meeting would be produced by the co-ordinating centre. Letters would be sent to all the MCAP members informing them about the meeting and asking for their contributions for the Newsletter and the city reports. In the afternoon after the opening ceremony of the international seminar of the Non Smoking County project all participants were taken for an interesting visit to the chewing gum factory which also produces nicotine chewing gum. This factory is an example of a smoke free working place which had also received the Non Smoking County Award for smoke free companies.
CITY REPORTS
BARCELONA In 1996 and 1997 the Barcelona City Health Department has been running a variety of actions regarding tobacco control. These activities have been oriented towards four main areas:
Educational interventions in school settings In previous years we have reported the development of the PASE project, a prevention curriculum aiming at 11-13 years olds. This is a ten hours educational module that provides an instrument for primary prevention of proven efficacy. In the 1996-97 school year the program was implemented in 141 schools.Year 1994 we reported the pilot implementation of a new educational module focusing on secondary school. Between 1995 and 1997 we have trained 181 new teachers and in the last school year, 81 secondary schools were implementing the program. In addition, a video linking non-smoking and sports performance, developed as part of the Smoke-free Olympics project, has been available to secondary schools and sport clubs since the academic year 1993-94. We are also involved in the ESFA project (European Smoking Prevention Framework Approach) that is a five years European smoking project. The project is a combination of intervention and research in a new approach to prevent young people from smoking. The aim of the program is to develop, implement and evaluate a comprehensive smoking prevention program in the school. The project is now in the preparatory analysis for development and next year we will report the progress. Expanding smoke-free environments and promoting smoking cessation. Our work in smoking control at the workplace has continued. Developed by the city Occupational Health Centre, it is based on company-based projects built on a consensus building process. This process involves policy setting on tobacco at the workplace, information and support for signalization, consultancy for the company occupational health services, support for prospective smokers including quit groups led by an experienced public health nurse. A new manual with guidelines for smoking control in the workplace is in press, to become the basis of a more systematic prevention package to be offered widely to workplaces. Through these actions, efforts to curb the socio-economic differential in tobacco use are made. For the 1996 International non-smoking day, was organised the second WHO CINDI Quit & Win program in collaboration with the Regional Government. Based on the wide dissemination of quit-contracts with a self addressed postcard format, it prompted the reception of over 1000 postcard of smokers in the city wishing to quit for a month. In order to determinate the impact of the campaign, a telephonic survey was carried out to collect information 12 months after the campaign. A systematic survey of 300 people was taken from population whose postcards contained all requested information. One year after the campaign, 28,4% are not smoking, the proportion being higher among females (34%) than among males (22,5%). With partial financial support of the EC program "Europe Against Cancer", and inspired in previous efforts targeting the primary schools, a global project to expand smoke-free areas in closed public spaces, specially those involving children, was developed over 1992-94. This project involves many agencies and community organisations in the city. It is based on facilitating the process of defining explicit policies on smoking by offering information, consultation, support material and signalization. Continuing previous efforts in school settings, we are doing a new project in secondary schools, where most smoking initiation seems to take place. During 1993-94 a survey was carried out to collect information on the baseline situation. Early in 1995, all secondary schools have received the main results of the baseline survey and an offer of support to define explicit school policies on smoking. This support included an order form for all schools that made available a manual with guidelines for the development of smoke-free areas, signalization, material, copies of the legal regulations on smoking in school, and the possibility of requesting a consultation to define policies on smoking. During the school year 1996-97, a second survey was carried to evaluate the impact of actions and the provisional results suggest that there is a higher presence of non-smoking signs and the restriction smoking by adults during the school operation hours. Currently we are involved in the "Smokefree Class Competition" project. The project is a school-based antismoking campaign. The target group of the campaign are pupils aged 12 to 15 years. The campaign will be carried out in co-operation with the "European network on Young People and Tobacco" (ENYPAT): The idea of this campaign was first established in Finland and it is a pilot project to test, whether the Finnish experiences can be adopted for other European countries. The campaign in the line with the recent priorities of Europe against Cancer Programme. The campaign is scheduled to take place over a period of three years. The first competition will be carried out in the school year 1997-98. Our aim for this school year is to involve about 80 classes in the project in the city. Monitoring the tobacco epidemic in the city Continuing previous surveys in 1987, 1992 and 1994, a sample of 1100 8th graders (13-14 years old) and 1100 of secondary schools (15-16 years old). The main results related tobacco consumption show that 6,5% of 14years old students in Barcelona are regular smokers and 26,4% of 16 years old students are diary smokers. The proportion at this age (16 years old) is higher among females (31,9%) than in males (18,4%.The Barcelona 1992-93 health survey, based on a sample of 5,000 persons among the non institutionalized population over 15 years provided new data on smoking in the city. The results provide an accurate picture of smoking in the adult population, with 32,8% persons defined as smokers and 13,4% as former smokers. Compared with a previous survey in 1986, these results show a clear decrease in the number of male smokers in young and middle age, a promising result linked to earlier quitting. In fact, this growing segment of young ex-smokers is a clear constituency for the advancement of non-smoking as the social norm. In contrast, the numbers of female smokers continue to rise as new cohorts of young women take-up the habit in numbers comparable to men, since the late sixties. On the other side, smoking women seem to smoke less than smoking men. Clear socio-economic, occupational and educational gradients are seen for smoking, and this has clear implications for a public health strategy based on the reduction of inequalities. This epidemiological information, as well as information on on-going projects, has been reported in scientific journals, but it also has been fed back to the community through press releases and contacts with the media, to introduce smoking control in the public and political agenda. Promoting smoking control activities in health services Since 1989 we are running a program of systematic minimal intervention by general practitioners to help smokers to quit. This program, based in a smoker card that fosters intervention in every visit, and uses a clinically oriented classification of smokers, according dependence and motivation, showed a quit rate near 20% in its pilot evaluation. Currently the program is recommended by the Spanish Society of Family Practitioners, through its program of Preventive Activities. During the year 1996 data were collected from 221 women smokers that gave birth in the Hospital del Mar of Barcelona. It was observed that 25% of the smokers pregnant women quit smoking spontaneously during the pregnancy ant that 33% of those which quit smoking were continuing abstinent six months after of the delivery. Since the pregnancy seems a timely moment to accomplish an intervention in smokers women that attend to the obstetrics outpatient department of this hospital. The program consists of medical advice for quit smoking in each strategies for quit smoking. The next year we will have results of the intervention.
FERRARA Global objectives for the Project "Ferrara - A smoke-free Healthy City" The main objective is the prevention of smoke-related neoplastic and degenerative diseases and a subsequent reduction in related mortalities.
Area and Means of Intervention In promoting activities to improve the quality of life by educating people toward healthy life styles, the "Healthy Cities" Project exploits of the principles of participation and exchange. The final aim is to build a "health-promoting community" the members of which work to enhance the health of the entire population. Adopting a global anti-smoking policy means simultaneously operating on several systems seeking an alliance between a city's social, institutional, political, economic and cultural organizations. The common goal must be to promote a collective consciousness to protect one's right to health, respecting oneself and others. This should take place through positive images and persuasion rather than by dissuasion: a campaign "against smoking" and not "against smokers". The areas of possible intervention indicated by the WHO are:
Local anti-smoking policies
Smoke-free public places and work sites
Smoke-free health services
New generations of non smokers
Aiding those wishing to quit
The Initiatives of the Project "Ferrara - A Smoke-free Healthy City" The general project is broken down into the sub-projects listed below. They are achieved through co-ordination and integration between the City, Health services, Schools, Neighbourhood Councils, Labour and Volunteer Organization.
Role of the Anti-Smoking Centre The Pneumological Unit of the USL 31 Health Care Service decided to set up the centre in 1989 to carry out research, education, training and therapy. The Centre acts as consultant for the educational and training aspects of the general practitioner counselling program organized by the health Ministry in June 1992, by the Republic of San Marino in January 1993 and by the USL Health Services of Bologna and Modena in April-December 1993, all under the auspices of the WHO "Healthy Cities"Project. The volume entitled "Medical Counselling for the smokers" edited by the Centre is among the counseling texts used by the Ufficio Autotutela della Salute (Office for Self Health Protection) of the City of Bologna. The Project "Ferrara - A Smoke-free City" is technically co-ordinated by the anti-smoking centre through the following activities:
The Coordinamento Aziendale per l'Educazione alla Salute (Corporate Coordination for Health Education) of the USL Health Care Service in Ferrara and Ser.T. (Servizio per tossico dipendenze - drug addition service) are also participating in the project. Timetable By the end of the 1st year
General evaluation criteria In line what has been indicated by the national oncological commission, general evaluation of the program will take place in three stages:
Dublin Healthy Cities, Dr. Emer Shelley Dublin Healthy Cities has had a number of successful interventions to control and reduce tobacco use:
National Context Legislation has been enacted to restrict the advertising of tobacco products. The legislation to control smoking in public places has been updated. The voluntary agreement with the tobacco industry to limit spending on sponsorship of cultural events continues to be monitored at national level. There is also a voluntary agreement that employers and trade unions will work together to control smoking in workplaces. Tobacco taxes have been increased in the annual national budget so that the cost of cigarettes has kept pace with inflation. This has helped to reduce tobacco consumption. Voluntary organisations lobby the Minister for Finance to encourage continued increases in taxation and removal of tobacco from the consumer Price Index.A National Cancer Strategy was published in 1997. Each health board is developing its own plan to implement the strategy at local level. A reduction in smoking prevalence will be an important component of the Eastern Health Board's cancer strategy. Smoking PrevalenceApproximately 30% of adult men and 28% of women are current smokers. In addition, up to 6% of men smoke a pipe or cigars or are occasional smokers. The prevalence of smoking has declined since the early 1970s but is now decreasing very slowly. Issues for concern are the slow rate of decline in women, children and young people, and the higher prevalence of smoking in those with low levels of education. The prevalence of smoking has been higher in adults in Dublin compared to the national prevalence. This explains some, if not all, of the higher standardised mortality ratio for lung cancer in County Dublin. There is evidence thet the excess prevalence in Dublin may have declined from 5% to 1% in the mid-1990s. There have been a number of surveys of smoking by school pupils. Different definitions of current smokers and different age groups were studied in different locations. The most recent national study (1993) found that approximately 29% of post-primary pupils (aged 12-18 years) were current smokers 16% were daily smokers. A survey of pupils aged 10-11 years in schools in areas with high levels of deprivation in Eastern Health Board found that 12% of pupils had smoked during the previous month. Issues and Challenges Legislation has been enacted on advertising of tobacco products, restricting smoking in public places and forbidding the Sale of tobacco to minors. A review of the implementation of the legislation on smoking in public places and on the sales of tobacco to minors is necessary. Inspection of the sign posting in public places with regard to restrictions on smoking would be the first step in examining the implementation of the legislation. The sale of smuggled cigarettes on the streets of Dublin has been a problem in recent years. In working in the community it is apparent that adults have low levels of awareness of the serious problem of smoking by young people in Ireland.There is substantial room for improvement in:
Dublin Healthy Cities Action Plan on Smoking The overall Draft Dublin Healthy Cities Plan (Phase I) was published in July 1997. The public were invited to submit their comments on the Plan. In addition, a range of organisations was invited to contribute their opinions on the Plan. The feedback received will be incorporated into the final plan for Dublin Healthy Cities, Phase I. The Dublin Draft Action Plan on Smoking will be updated in the context of the WHO Draft Action Plan for a Tobacco Free Europe. The Dublin Healthy Cities Action Plan on Smoking will include the following:
BOLOGNA Actions for a tobacco free city promoted by Bologna Dr. Cappecchi On July 9th 1997, Bologna-Healthy Cities Project Office organized the second meeting of the Italian Tobacco-free Multi Cities Action Plan (MCAP) Network. During the meeting a revision of cities on their tobacco control activities was made. To make this revision easier a questionnaire was sent to collect information about programs and actions organized by the Municipalities joining the national Network. Comparing the activities carried out by different Municipalities it was found that working methodologies and strategies have been very similar, so far:
As stressed in previous meetings, objectives to reach are:
The Italian Network agreed on the following work plan:
Co-ordination of self-projects of different network Municipalities
In September 26, Rome Municipality, along with Bologna municipality and the National Network as a partners, has promoted a National Meeting entitled: "Health and Towns towards 2000". Case studies of several Network towns have been reported during the afternoon: Bologna, Milano, Padova, Prato, Udine, Monfalcone, Casale Monferrato, Roma, Pistoia, Catania, Napoli about healthy policies (Tobacco, woman's-health, alcohol, AIDS, environment and electromagnetic pollution…) Dr. Angela Messori (Bologna HCP), made a brief presentation about objectives and working strategies adopted during the three National Tobacco MCAP Co-ordinator's meetings. Smoking prevention activities has been mainly directed to young people. The "Bologna No-Smoking Project-Group" in partnership with provincial Educational Office provided a "Formation Course for Teachers" to prevent smoking-habit in the Schools. The 27 hours Course lasted from November to December c/o the Bologna Epidemiological Monitoring Institute. Meetings were focused to raise awareness about harms for health, cessation strategies, prevention actions, to give expertise to cope with stress. Epidemiological Monitoring has started for different age classes. The course was joined by 40 teachers from Secondary and High School of Bologna and Province.From November 24 to 26, HCP has been evaluated by WHO Delegation from London School of Economics and Political Science (Dr. D. Berkeley and L. Garcia) and Maastricht University (Dr. E. de Leeuw) to find out how the projects have been introduced, Dr. Vittorio Capecchi, the Tobacco free Healthy Cities MCAP Co-ordinator, illustrated up to date program phases and foretold the Group commitments as far as strategies and sectors were concerned (work places, healthy policies, school) and actions (counselling, smoking cessation courses). The issue "Smoke harms your growing up. No-Tobacco School" has been translated in English Language with the commitment of "N. Copernico" High School under the supervision of Prof. Anna Maria Albertazzi. In the mean time students of "F. Besta" Secondary School performed its ipertext-linkway conversion under the supervision of Prof. Gino Fabbri and Lia Bedocchi. HTLM version of the above mentioned booklet is now available in Internet with very interesting information not only reserved to students or young people, but also for general population. It represents the mainstream of WEB site of "Bologna No-Smoking Project", under the following address: http//kidslink.bo.cnr.it/besta/fumo.
GENEVA Three general goals of CIPRET (The Information Centre for Tobacco Prevention)
These objectives have been carried out through a variety of activities:
On the 17th of April, 1996, the State Council of Geneva (government) took a decision with two main points in mind: the protection of non-smokers from passive smoking and the encouragement of programmes to help smokers to break the habit, if they so desire. These ideas were implemented via a programme put in place when the State of Geneva declared itself as "Without smoking but not without smokers" within all buildings providing State services. This decision was not taken on a whim. In 1985, the State Council of Geneva had already made many recommendations which, in general, suggested the following:
From that point on, many services began applying these suggested rules to treat non-smokers with more respect than has been the case in the past. This decision is part of a larger project on health management in the State enterprise. This includes management of alcohol dependency problems at the workplace work-related stress management accident prevention hygiene promotion general public health etc. Its implementation relies on legal, socio-professional and scientific ideas that unfortunately cannot be described in detail here, due to lack of time and space. Concrete solutions
Sharing the information The goal was to explain that the objective of the procedure is to be respectful towards smokers and non-smokers alike and not only to maintain good working conditions without descriminating against smokers, but also to promote and practice a friendly cohabitation where everyone is a winner. Hence, the creation of the slogan "For a State without smoking, but not without smokers". Selecting the smoking areas
While, in general, we have managed to propose an acceptable solution for all parties concerned, this has not, unfortunately, always been the case. We have been faced with invincible obstacles, usually due to architectural barriers (ie: windowless hallways, insufficient ventilation, etc.) where rearrangement would have been too costly. In these rare cases, we have not always been able to respect the above mentioned criteria. Communication materials Methods for breaking the habit of smoking Dietary counselling A positive interim report As a preface, we could say with confidence, that the frame of mind concerning the desire to protect oneself from passive smoking is popular. As proof, we have the constructive climate that reigned for the first 15 months of the campaign whenever there was as intervention by the HSSP in the governmental services. According to 70 returned questionnaires (a sample representing 6000 individuals), we can be satisfied with the measures taken. In fact, the HSSP gave specific information to approximately 1500 people, while over 2000 received supplementary information through their department and 2500 received information indirectly. The information given by the HSSp was seen as entirely adequate. Over half of the time, smoking areas were put in place. When the survey was conducted, there were over 65 new smoking areas, all apparently well-respected. Many department heads plan to create a smoking area in the future, as they have until the end of 1998. However, in half of the cases, smoking is still permitted in individual offices. The material given to the services was, in general, very well accepted. It could be said that the first months of the campaign were advantageous to nearly half of the State administration for the implementation of regulation concerning passive smoking. Finally, no.one will be surprised at the fact that implementation becomes much more difficult when the department head is a smoker. 2. Action taken in public establishments (cafes and restaurants) The CIPRET also develops activities in public areas, especially cafes and restaurants in the State of Geneva. These activities are focused on the promotion of non-smoking areas in the majority of these establishments. Please note that in Switzerland, there exists no legal obligation for public establishments to install smoking and non-smoking areas. The only legal restriction that exists is an ordinance pertaining to the Law on Work put into place on the 1st of October 1993. The ordinance is as follows: Article 19: "The employer will be mindful to protect the non-smokers from being inconvenienced by the tobacco smoke of others as much as it is possible in the setting of the enterprise." The promotion of smoking and non-smoking areas is therefore a result of the sensitisation campaigns. In this domain, the actions of the CIPRET are re-enforced by the activities of the Association Fourchette verte which has launched a label of quality for restaurants in Geneva. The Fourchette verte label is given to establishments which meet these four criteria:
GDANSK The City of Gdansk, in operating the "Healthy City" programme is currently paying particular attention to the combat of nicotine addiction. From occasional activities in the past, we are now developing our approach to include sistematically planned action. We enclose the scheme for the City of Gdansk in relation to this. We also wish to inform you that, above all, our action is being directed at young people who have already started smoking or who intend to do so. Children and teenagers taking part in a poster and drawing competition are providing us with ideas and sharing with us their views on this dangerous phenomenon. We, for our part, are making use of their ideas to run anti-nicotine campaigns on public transport and public advertising bill boards in places frequented by teenagers and adults. This cooperation is producing excellent result. The young people whose drawings are used feel appreciated.We consider that for one to be a non-smoker should be a source of pride and we regard inclusion in MCAP to be a great privilege. We hope that this privilege will become ours through the acceptance of our application by the European Regional Office of the W.H.O. and we draw attention to this request once more. In our activities we endeavour to combine the efforts of many institutions and organizations and to win over supporters of the "non-smoking" vogue among commercial enterprises (profit-making) and insurance companies, as well as firms trading in nicotine-substitute products who have sponsored a number of our activities.With a view to greater prevention of smoking-related diseases, the majority of our Regional Health Services give out information and educate on this subject. Apart from this, the Regional Tuberculosis and Lung Disease Clinic is involved in organizing regular informal lectures, competitions and tests on the subject of harmful affects of smoking (particularly for and among school pupils). This programme is known as "Your Health in Your Hands" and is supported financially and technically by the "Polish Healthy Cities" Association. The clinic also provides therapy for people addicted to smoking, employing the skills of doctors and psychologists for this purpose. We wish to present our programme of anti-smoking activities to other cities and help them to introduce it as we consider it to be very worthwhile. The City of Gdansk it conscious of the gravity of the situation, and is aware of the weight of responsibility for the health it carries for the health of its inhabitants. Therefore, we confirm our readiness to observe the rules of the programme "Multi-City Action Plan" (MCAP) and our commitment to prepare and effectively carry out the action plan of the city in this respect. In support of this, we enclose documents further outlining our plan. We intend to appoint an Inter-disciplinary Group responsible for overseeing the Action Plan to Solve Nicotine-Based Problems within the programme "The City of Gdansk Freed the Plague of Tobacco". The City of Gdansk will present an annual report and other information requested by MCAP. We hereby enclose documents and an outlined plan connected with the above-mentioned programme. Once again we draw your attention to our request to be involved in the group of cities involved in the next phase of MCAP. Technical and organizational responsibility for action against nicotine addiction - Local Coordinator of "Polish Healthy Cities" programme in Gdansk - Ms. Zofia Gosz - appointed by Gdansk City Council. Projects for a Tobacco free Gdansk
Annex 1 WORKING GROUP: MOBILISATION AND EVALUATION Consider a strategy and how to evaluate it.
GROUP 1 (Lane 8) LOCAL ELITES Who are the Local Elites:
How to mobilise Local Elites
How to evaluate progress and results:
GROUP 2 (Lane 9) MEDIA Mobilising Media Problems:
How to mobilise:
Why to mobilise:
How to evaluate:
GROUP 3 (Lane 10) PUBLIC/PEOPLE How to mobilise:
How to evaluate:
Annex 2 Tobacco Action in Healthy Cities Sonja Danen - Intern of the WHO Healthy Cities Project Office Introduction It is Known that tobacco is the major cause of lung camcer, ischaemic heart disease, chronic bronchitis and emphisema. But despite this knowledge and the fact that smoking is becoming less acceptable in Europe, it is still a part of the daily lives of many people (1). Fortunately, the general pattern of tobacco consumption in European countries has changed a lot during the last decade in a positive sense. Health promotion has already made many efforts to decrease smoking consumption, but as long as people still start smoking we should not lose sight of this important issue. One of the targets of the Health for All strategy is about the tobacco issue: Target 17: Tobacco, alcohol and psychoactive drugs. "By the year 2000, the health-damaging consumption od dependence-producing substances such as alcohol, tobacco and psychoactive drugs should have been significantly reduced in all Member States. Increase the number of non-smokers to at least 80% of the population and protect non-smokers from involuntary exposure to tobacco smoke" (1). This target, together with Health for All target 14 (Settings for Health Promotion. "By the year 2000, all settings of social life and activity, such as the city, school, workplace, neighbourhood and home, shoul provide greater opportunities for promoting health"), provides the base for the work of the Healthy Cities Project on Tobacco (1,2). One of the designation criteria for the cities to join the second phase of the healthy Cities Project is: "All project cities should take active steps to take on the Who European strategic action priorities and in particular to implement the European Tobacco Action Plan and the European Alcohol Action Plan" (3). Since we are almost at the end of the second phase of the Healthy Cities Project, the time has come to identify the state of tobacco action in the cities and to determine their efforts to meet to this criterion. This paper will provide a short description of the state of tobacco action and policies in the cities that are taking part in the Healthy Cities Project. I will first give a short review of the history of the tobacco issue and some of the decisions that were made in the past concerning this issue. The second part of this paper will describe the methodology and the paper will include with tentative findings and recommendations for further research. History of tobacco action in the healthy Cities Project The first Action Plan on Tobacco was adopted by the 32 Member States comprising the European region of WHO in 1987 (2,4). This action plan was build on the principles of the Ottawa Charter for health promotion and the health for All targets(49. This five-year plan included 6 basis rights and 10 strategies for a smoke free Europe. The basic rights for a tobacco-free europe include:
The year after the adoption of this plan, the first European Conference on Tobacco Policy took place in Madrid. At this meeting all the member states agreed to promote nonsmoking and smoke-free environments (1,4) and subscribed to the Charter against tobacco. In 1989, at a Healthy Cities Business Meeting in Belfast, many cities shared the idea for developing more intense international collaboration on tobacco. At this meeting the idea for a Multi City Action Plan (MCAP) on Tobacco was born. This MCAP is primarily based on the Action Plan on Tobacco and the principles of the Healthy Cities Project (2). The next meeting in 1990 and 1991 were devoted to the formulation of the key themes for intervention: children, economic issues, local government, public places, health services, and adult in the community (2). The MCAP on Tobacco ever since has worked together in many activities on tobacco and the joining cities have had the opportunities of sharing knowledge and experiences. Possibly, the most known action of this MCAP might have been the "Quit and Win" competition (2). Since the first Action Plan on Tobacco was a five year plan, it has been revised in the meantime. One of the most important conclusions that could be drawn from the first phase of tobacco-action, was that a multisectoral approach on this issue is very important. Decrease of tobacco consumption is hard to be reached without taxation and juridical steering (2,5). Therefore the second Action Plan on Tobacco is mainly focused on the multisectoral implementation process (2,5). However the action areas, the key themes, and the ten strategies for a Tobacco-free Europe are still the same. At this moment we are standing at the cradle of the 3rd Action Plan for a Tobacco free Europe that will describe the strategies for 1997 until 2001. This plan will be based on an evaluation of the progress that is made by Member States and WHO (7). This new plan stresses the need for determined action to protect the European citizens form the activities of the tobacco industry. Research Questions Did the cities that are partecipating in the Healthy Cities project really pay attention to the designation criterion concerning tobacco? What kind of action is undertaken in the cities concerning tobacco? Is being a member city of the MCAP on tobacco an advantage to develop good policies on tobacco? These are few of the many questions that are to be evaluated now we are at the end of the second phase of the Healthy Cities Project. By this analysis and policy evaluation of this actions in cities on the tobacco-issue, it is tried to provide some answers on the above questions. There are two main aims of this research. The first is to provide a description of action in the cities to adapt WHO strategies and guidelines to the municipal level. And second, to generate preliminary hypotheses about the role of selected policy-related factors in stimulating the development of local policy on tobacco. Methodology Based on Business Meeting Reports, the Healthy Cities Project designation criteria for the 2nd phase, the WHO Tobacco Action Plan, and MCAP on Tobacco publications, the next issues were identified as key areas in this investigation:
Data gathering took place in two ways. The first method by which the information was collected were semi-structured telephone interviews. All the coordinators of the cities partecipating in the Healthy Cities project were called and the next questions were discussed:
These questions do certainly not cover all the important aspects of tobacco policies and action in the cities. A broader, and probably more complet, evaluation of this issue was not possible because od the short time-table in which this reasearch took place. It is tried to fill this gap by concluding with some recommendations for further research on tobacco at the end of this paper. The above questions were first tested on 3 cities. The second way for information collection was an examination of written progress reports that cities had sent to the healthy Cities Project Office in 1996. Data collection Of the 36 project cities, 31 coordinators were interviewed. This is a response of 86%. It was chosen to interview the coordinators of the cities because these people would have a good overview of the activities within their project. WHO had received 28 progress reports of which 15 (42% of all project cities) included a description of the tobacco actions and/or policies in the city: most of the questions could be answered by the gathered information. However, some data are missing. This was due to the semi-structured way in which the interviews were carried out. Sometimes the language was also an obstacle to collect the information very precisely. In general, it can be concluded that the interviews were a good tool to get a clear picture and impression of tobacco actions in the project cities. By means of the interviews it was possible to ask immediately for more specifications about certain project. The progress reports provided good background information for carrying out the interviews and functioned as comparison material for the information that resulted from the interviews. At a result of the interviews, some coordinators send some additional information which was also used for answering the questions. The next section will give a short analysis of all the questions. For more information, the raw data are also presented in the appendixes. Results Tobacco programmes The first question addressed the educational programmes that the cities have undertaken. Educational programmes on tobacco were defined as activities that try to give the target groups more knowledge about the harmful effects of smoking and information about how to quit smoking. The purpose of this question was to get an overview of the actions on tobacco in thecities and the way they are structured. Of the 31 respondents 26 replied that they had developed some or many educational programmes on tobacco, of which three stressed that they had some activities, but those were very weak. Four of the fives cities that did not develop specific educational programmes at local level, gave the argument that these programmes are already developed at national level. More than half (55%) of the respondents organized this kind of programmes by themselves, 28% developed the programmes in cooperation with other organizations, and in 13% of the cities this kind of activities were developed by other organizations without involvement of the healthy cities project. The programmes in the cities globally be devided in the next categories: programmes in schools, programmes in universities, programmes in workplaces, research on tobacco, actions at World Tobacco Day, campaigns, actions at public places, and programmes in hospitals. However, not all of these programmes can be categorized under educational programmes. Of the above categories, it can be concluded that many cities develop programmes in schools and undertake actions for smoke free public places. The nature of the programmes differs from campaigns and role plays for pupils, to production of guides for smoke free restaurants, to the development of local action plans on tobacco and presentations of advertizing strategies of the cigarette industry (appendix…). Since many cities develop programm in schools, it is not surprising that the main target group of tobacco programmes in the project cities are (school-) children (in 42% of the cities). 23% of the cities focuses the programmes on the entire population. Other target groups that are often used are women, youth, and adolescents. Passive smoking Passive smoking seems to play an important role in the tobacco programmes that are developed in the project cities: "Passive smoking is the strenght of the programmes. People are allowed to smoke, but they are not allowed to be harmful to other people's health. Programmes focus on the right for a non-smoker to live in a smoke-free area and to breath smoke-free air" (Gothenburg). This reflects in the fact that 71% of the 31 cities pay attention to passive smoking in their programmes. This is mainly done by national legislation and /or campaigns again in programmes for children, by lobbying at members of the city council. But an other way to bring this issue to the attention of people is the organization of a symposium on passive smoking, as was done in Kaunas. Smoking cessation programmes Many cities (71%) help theur citizens when they want quit smoking. This support is provided by different kinds of programmes: Quit and Win contests, quit smoking courses in general, quit smoking courses in hospitals, quit smoking courses at the workplaces and campaign for stop smoking. 65% of the respondents has developed quit smoking courses in the general category. Half of these courses are open for all the citizens. Other important target groups are women, patients with pulmonary heart diseases, people who work with children, and youngsters. Apart form a lot of different target groups, the organization of these courses is also in the hands of a range of different institutions. A few examples are: the Cancer League, healthy cities shops, home care organizations, private organizations, Healthy Cities in cooperation with other organizations, etc. (appendix). Programmes for children / young people Many project cities have developed special programmes for children and young people (84%). Based on the answer, a categorization is made of the different nature of programmes for this target group: school education programmes, competition in/between schools, campaigns, programmes at national level, and a category "other". Examples of this last categories are publications of booklets, drawiong competitions, a mini-marathon race, and the aim to be prsent at all event for young people. 21 of the 26 project cities that developed special programmes for children and young people undertook education programmes in schools. Often they work with guest teachers what seems to be very successful, and in some cases the tobacco education is integrated in general Health Promotion programmes. Competitions between schools also seem to be a quiet popular way to educate children about tobacco. In 4 cases the cities took part in programmes that are developed at national level, or they did not undertake any addictional activities, since these were already initiated and impemented at national level. A local written tobacco control policy A written tobacco control policy is only available in some of the project cities (26%) for several reasons. The most mentioned reason is that it is already regulated at national level. Some other reasons are problems with tobacco factories that are present in the country (Geneva), or that the city does not have the competency to regulate this locally by lack of a national law (Pecs). Two cities hoped to produce a local written tobacco policy in the near future, Liverpool and Maribor, respectively based on a seminar and a charter. Different aspects that are included in these written policies are: banning of smoking in municipal buildings, policies on smoke-free places, a general description of anti-tobacco activities in the city, and Torun even has a local law that forbids the sale of cigarettes to children. In Gothenburg is this local not used anymore, since a national law took its funcion over. Public places The conclusion of the first question of the interview that many cities pay attention to tobacco policies in public places is confirmed by the outcomes of question 5: 87% of the respondents has programmes in this field. This 87% also includes national laws. Of this percentage 37% of the cities also developed programmes at a local level. The presence of a national law is for many cities a reason for not being active in this field: "The healthy citiesd project of Dublin initiated policies for smoke-free public places. Later, national policies were developed and at this moment all the public places are smoke-free" (Dublin). Some cities, however, stress that the national law is not very much attended, but have not developed local actions to fill this gap for example by facilitating the implementation of the law. The local actions in this field are again of different nature. Some cities have pay some attention to it in campaigns and educational programmes, others developed special programmes for smoke-free restaurants: "Green Fork Action: the green fork label accorded to restaurants respecting 4 criteria's (hygienic cooking and storage conditions, a daily healthy meal, a non smoking area, chap non-alcoholic beverages). The restaurants have the green fork label on the front door and are included in a booklet with the green fork restaurants. They also have small leaflets on the tables about the green fork label" (Geneva). Some cities met some problems in implementation of plicies for smoke-free places at local level they would like to have support from for example a clear national law (Gyor, Pecs). Governmental buildings In 19 of the 31 cities, local or national policies regulate non-smoking in governmental buildings. In these cities there are non-smoking policies in governmental buildings. Only 9 cities of these developed policies at local level. Again the presence of a national law was a reason for cities to have no activities in this field, or to stop the activities that they undertook before. Unfortunately, again the presence of a national law does not provide a prerequisite for smoke-free governmental buildings (Bologna, Brno). Workplaces The response onthis question was very low (only 24 responses). However, 20 of these cities have developed non-smoking policies at workplaces (10 cities) or there are national policies in this field (13 cities). Again, sometimes tjhe national law is not sctrict enough or hard to implement (Lodz, Brno, Geneva). The local actions vary from encouragement of workers (Belfast, Glasgow) and employers to banning of smoking in all workplaces (Koscise). In general it happens to be difficult to implement this kind of policies without forcing the people. Very strict rules seem to be necessary for successful policies in this field. Tobacco advertizing Controls on advertizing are implemented through national legislation or local agreements. About 20 cities have a legislative ban of tobacco advertizing at national level and 5 cities and 9 cities developed actions against tobacco advertizing at city level. In general this seems a very difficult fiels for developing successful activities. Several cities tried to discuss the banning of it in the city, but often this was without success. In Koscise, however, the city agreed to ban tobacco advertizement by a city by-law and in Dresden tobacco advertizing is allowed in 20% of the city due to a contract between the city and the advertizing agency. The national laws are not always strict enough. For example in Vienna, it is possible to advertize with another product with the same name as tobacco products, and in Pecs tobacco advertizing still takes place despite of the law. Discussion and recomendations Based on the results of the interviews and examination of progress reports and additional documents, it can be concluded that tobacco activities are an important issue in many of the project cities. Many cities develop programmes that work on the 6 basic rights for a tobacco-free Europe. A lot of activities are developed by the healthy cities project office or in cooperation with other organizations. It seems that the concept of intersectoral action has developed well in the field of tobacco action. Unfortunately many cities are not keen to work on the tobacco issue because other organizations already work on it or because there are national policies for it. There is somethingto say for this of course. Why develop a national policy on tobacco if everything is already regulated in a national law? It is not strange that cities in such countries focus on other issues. However, there is also an other possible way to take when there are other institutions working on tobacco or when there are already national policies. For example, Belfast only wants to do new things that are not yet done by other organizations. So they develop activities that are additional to the actions of others. Since a national law or the activities on tobacco of other organizations can not be perfect and complete yet, there is always work to be done by the project cities. Especially because it is also one of the aims of the 2nd phase of the Healthy Cities Project. As said, many cities have developed actions and programmes in the field of tobacco that fit in three of the four key areas of this investigation (Children, Public Places, Health Service). However, the action of the citiesin the fourth area, Local Government is quiet brief addressed by most of the cities. One of the aims of the Healthy Cities Project is to get health and health-related issues on the political agenda at city level. But only a few citie have developed a written tobacco policy in their city. It is very important to continue or start working at getting the attention of politiciansfor the tobacco issu. The last years, many progress is made in this field, but as long as people start smoking and people die from smoking, there is still work to do. Summarized, it can be concluded that action is undertaken in already a lot of areas that are mentioned in the Action Plan for a Tobacco Free Europe, but that more action should be undertaken at policy level. Especially in the countries where the tobacco factories are still having a lot of freedom and many people are influenced by their advertizing, it is very important to stress the importance of policies of non-smoking policies. Legitimation is often needed before concrete actions can be successful. Unfortunately, it was not possible to do an in-depth investigation of the different programmes on tobacco of the project cities. However, it can be recommended to do further investigation in this area for two reasons. First, there is still a lot of information available in the documents that are the cities have sent to WHO as a result of the interview, and second, it would be very useful for cities to have examples and case-studies available from other cities. References
Draft Third Action Plan for a Tobacco Free Europe 1997-2001. Copenhagen, WHO Regional Office for Europe, 1997 (unpublished document).
LIST OF PARTICIPANTS Dr Peter Anderson Mr Artur Antczak Mr Cristopher Johnson Dr Maurizio Laezza Mr Jaroslaw Lorek Mr Roman Lysek Ms Laurence Fehlmann Rielle Dr Emer Shelley Dr Elizabeth Tamang Participants from the Non-Smoking County project. Ms Lisbeth G. Petersen Ms Hanne Dahlerup Jensen Mr Finn Sørensen Tobacco free Healthy Cities MCAP MembersCITIES Ms Arlene Spiers Dr Vittorio Capecchi Dr Emer Shelley Dr Maurizio Laezza Ms Zofia Gosz Ms Laurence Fehlmann Rielle Dr Tomas Stanikas Ms Alina Walaszczyk Mr Pedro Oviedo de Sola Mr Antonio De Blasio Mrs Malorzata Torunska WHO/EURO Dr Peter Anderson Co-ordinating Centre Dr Elizabeth Tamang
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