Chapter one

European Tobacco Control Initiative: from Helsinki to Las Palmas de Gran Canaria.

Lluis Serra-Majem, MD, MSc, Ph D1

José Ramón Calvo, MD, PhD[1], [2]

Francisco Santana, MD, MPH1

Juan Carlos Orengo, MD, MPH1

Anselmo López-Cabañas, MD2

Pedro Serrano, MD, MPH, PhD[3]

A bridge across Europe

In the old continent, the tobacco industry is still able to perform aggressive media campaigns that would never be permitted in, for example, the United States or Australia. One of these was the campaign comparing the relative risks of certain diseases related to tobacco exposure to the risks of drinking chlorinated water or consuming cookies or pepper.

The Helsinki meeting opened the door to sharing experiences between those European professionals worried about the health consequences of tobacco, people active in legislation, young people, women and people active in the media. In addition, Finland and other north European countries. have a history of effective measures against the tobacco industry that need to be presented to southern and eastern European countries, including Spain. It is partly for this reason that the second Smokefree Europe conference will take place in Gran Canaria, in February 1999.

Tobacco consumption in the Canary Islands

• Some 37% of adult Canarian inhabitants smoke, including nearly 40% of health professionals.

• Tobacco is an important economic resource for the Islands, employing over 2,800 people and accounting for an annual economic turn over of Pta 72,000 million (1 ECU= 168 Pesetas). It is an unique European location of four of the leading multinational tobacco industries.

• The publicity investment of the tobacco industry in Canary Islands is high, with more than Pta 1,700 million invested last year by one of the tobacco giants alone.

• The economic costs of the tobacco impact on the health system is estimated to be over Pta 16,000 millions, more than 10% of the budget of the Canarian Health Service.

• It is estimated that smoking is responsible for 14.7% of deaths in the Canary Islands, representing 1,475 deaths every year, compared to the 2,800 employed in the tobacco industry

Venue

New health policy against tobacco

The first included a survey of 124 focal groups in 72 municipalities that fielded questions on perceived health needs, health problem prioritisation, the relationship between lifestyles and environment and health status, and opinions on actions to be undertaken at individual and governmental levels. Results from this survey showed that tobacco and alcohol were considered the main perceived problem and the first priority.

The consultation with health professionals included physicians, nurses, pharmacists, dentists, psychologists, health workers and vetenerians. The survey technique to estimate the opinion of some 1,199 health professionals using an Anchord Rating Scale rated from 1 to 6 in exploring health status, living conditions and provision and use of health care services. Alcohol and tobacco were rated as the third priority, after diabetes and cardiovascular diseases, by this group of health professionals.

And the delphi survey of opinion leaders and health experts used the Hanlon method to set priorities--comprising seriousness of the health problem, responsiveness to intervention, feasibility, possibility to evaluation, efficiency and costs. Smoking was rated as the third serious lifestyle problem after illegal drug use and alcoholism, and as the fourth health problem after cardiovascular diseases, cancer and diabetes.

Because of this, cutting smoking is a health priority for the Canarian Health Service--which is the reason for the Service's support, together with the University of Las Palmas de Gran Canaria, for the development of the second European conference.

One of the initiatives on the agenda of the Canarian government is the development of a special tax on alcohol and tobacco -never before imposed in Spain.

The final aim is clear: a Smokefree Europe, north and south. n

TABLE 1 MORTALITY ATTRIBUTABLE TO SMOKING IN THE CANARY ISLANDS (1995)

Cause of death	Code CEI-9a	Deaths 1995		PAP (%) *			Attributable deaths
		Males	Females	RR	Males	Females	Males	Females	Total
IHD	410 a 414	785	622	1.8	28	17	220	106	326
CVA	430 a 438	391	484	1.8	28	17	109	82	191
PVD	443	15	15	1.5	19	11	3	2	5
COPD	490-496	266	105	12	84	74	223	78	301
CLB	162	425	61	10	81	70	344	43	387
CLTMP	140 a 149	92	11	6	70	56	64	6	70
CL	161	71	2	6	70	56	5	1	6
CE	150	57	8	5	66	51	86	4	90
CP	157	71	54	2	32	20	23	11	34
CUB	188	86	10	2.5	42	28	36	3	39
CK	189	22	7	2.5	42	28	9	2	11
CC	180	-	32	2.1	34	22	-	77
DNB	765, 769 y 770	10	6	1.8	28	17	3	1	4
SDS	798	16	5	1.5	19	11	3	1	4
Total		2307	1422				1128	347	1475
Total deaths		5655	4423
P(RR-1) *PAP= -------- x100						Source: ISTAC, 1995. Serra-Majem et al, 1997.

IHD is ischaemic heart diseases, CVA cerebrovascular diseases, PDV peripheral vascular diseases, COPD chronic obstructive pulmonary diseases, CLB lung cancer, CLTMP cancer of the lip, mouth and pharynx, CL cancer of the larynx, CE cancer of the oesophagus, CP cancer of the pancreas, CUB cancer of the urinary bladder, CK other cancer of the urinary organs, CC cervical cancer, DNB diseases related to smoking during pregnancy, SDS sudden infant death syndrome.

Correspondence:

Professor Lluis Serra-Majem, MD, Ph D

Chairman,

Department of Public Health

School of Health Sciences

University of Las Palmas de Gran Canaria

P.O. Box 550

35080 LAS PALMAS DE GRAN CANARIA

Spain

Tel. 3428-453476

Fax. 3428-453475

e-mail. serra@mpsp.ext.ulpgc.es

Rising Profile of Smoke-free Concerns

...attitudes toward smoking are changing among the coming generation of health professionals, and are likely to be reflected in patient counselling.

But a survey conducted in 1996 by the researchers of the smoking habits of students and teachers at the medical school and found some encouraging signs of declining tobacco use. The sample survey polled 154 students and 65 teachers. The number of regular smokers among the teachers was 38.5%-67.7% were former smokers. Of the students, 31.3% have smoked in the past and 18.3% still did.

The study is seen as evidence that attitudes toward smoking are changing among the coming generation of health professionals, and are likely to be reflected in patient counselling.

Recent target

In 1996 the proportion of smokers in the population was put at 36% of the nearly 40 million population. Morbidity studies attribute 40,000 deaths each year to tobacco use, and WHO figures put the proportion of lung cancer deaths due to smoking at nearly 90%. Studies at the Universidad Automa de Madrid show that for every gram increase in tobacco consumption per capita per day since 1940 there has been a corresponding increase in lung cancer deaths by 20%.

Sun, sea and smoke

Spain's popularity as a holiday destination does not escape the tobacco industry's marketing gambits. The advertising of fun and lifestyle products rockets each summer, with about 30% of ad companies' outdoor commercials devoted to summer campaigns. Prominent among the big names are Marlboro and Winston.

...youth is the target, and the Canary Islands a prominent focal point due to its leading position in the holiday industry.

More attention to curtailing cigarette adverts was prompted in 1995 when Philip Morris began advertising for smokers' rights and the next year when the company launched its campaign to undermine efforts to cut passive smoking. Similarly, more attention is being placed on limiting smoking in public places, a development which, according to a 1995 opinion poll conducted by the Centro de Investigaciones Sociologicas, has over 43% public support.

On the defensive

The drop in cigarette sales does not necessarily reflect rising anti-smoking awareness. A more likely explanation is the erratic influx of contraband cigarettes into the country. About 30% of Marlboro and 60% of Winston brands are contraband. In 1996, Spanish customs stopped a shipment of some 600,000 cartons of cigarettes worth US$1.4 million that had travelled from Finland. Authorities traced the consignment to a Russian source, and suspected that it was part of a mafia operation. Though cigarette smuggling is not a central campaigning concern of the anti-smoking lobby, it is nevertheless seen as an additional factor responsible for the prevalence of tobacco in society, and in particular its intensive sale and consumption in holiday resorts. n

Mark Waller

Smoking Cessation Intervention in Gran Canaria.

The course programme applies a multiple component programme that includes the progressive reduction of nicotine and tar. The courses comprise five weekly sessions and the provision of a short self-help manual. The positive results of the courses have encouraged the organisers to ensure they continue.

The results of data collected through participation in the courses show that more women than men have been drawn to the courses. They also attract a high percentage of heavy smokers--89% smoke 20 or more cigarettes a day. The results show that the best results have been obtained through small group sessions, weekly periodicity and the use of the support-manual. n