Effect of Advertising Bans

Within฀15฀years฀following฀the฀general฀ban฀on฀tobacco฀advertising฀that฀has฀existed฀in฀ Norway฀since฀1975,฀there฀was฀a฀decline฀in฀the฀number฀of฀adolescent฀smokers฀of฀5–10,฀ depending฀on฀age฀group฀and฀sex,฀with฀total฀smoking฀prevalence฀reductions฀of฀10฀among฀ 16–24-year-old฀men฀and฀20฀among฀women฀of฀the฀same฀age฀ [96,฀97] .฀Smoking฀preva- lence฀also฀fell฀among฀older฀people฀within฀15฀years,฀with฀igures฀of฀35฀for฀men฀and฀32฀ for฀women฀being฀reported฀in฀1995฀ [98] .฀Overall,฀per-capita฀tobacco฀consumption฀fell฀from฀ 2,100฀to฀1,553฀g฀during฀the฀period฀from฀1975฀to฀1996฀Fig.฀ 13.9 ฀ [99] . In฀Finland,฀the฀ban฀was฀implemented฀in฀two฀phases฀in฀1977฀and฀1994:฀in฀the฀second฀ considerably฀more฀stringent฀phase,฀cigarette฀advertisements฀were฀also฀prohibited฀in฀for- eign฀magazines,฀which฀are฀extremely฀popular฀in฀Finland.฀The฀greatest฀decline฀in฀smoking฀ prevalence฀ was฀ recorded฀ among฀ men฀ [100] .฀ During฀ the฀ period฀ 1978–1996,฀ per-capita฀ tobacco฀consumption฀fell฀from฀2,134฀to฀1,350฀g฀Fig.฀ 13.9 ฀ [99,฀101] . The฀advertising฀ban฀introduced฀in฀New฀Zealand฀in฀1990฀resulted฀in฀a฀reduction฀in฀per- capita฀tobacco฀consumption฀from฀1,957฀to฀1,553฀g฀1990฀vs.฀1996.฀Over฀the฀same฀period,฀ the฀number฀of฀adolescent฀smokers฀fell฀by฀1.9฀ [99] . In฀France,฀a฀ban฀on฀tobacco฀advertising฀has฀been฀in฀place฀since฀1993.฀Within฀4฀years,฀ per-capita฀tobacco฀consumption฀fell฀from฀2,970฀to฀1,834฀g;฀despite฀this฀fall,฀no฀reduction฀ in฀smoking฀has฀been฀reported฀among฀12–18-year฀olds฀Table฀ 13.3 ฀ [99] . Country Introduction฀of฀ advertising฀ban Reference฀year฀ for฀evaluation Reduction฀in฀consumption฀among฀ adolescents฀by฀1996;฀in฀Germany฀฀ by฀1993 Norway 1.7.1975 1975 −15.8฀boys;฀−15.4฀girls Finland 1.3.1978 19781979 −12฀boys;฀−14฀girls New฀Zealand 17.12.1990 1990 −2.1 France 1.1.1993 1992 Germany – 1993 −5.4 Table 13.3 ฀฀฀Reduction฀in฀percentage฀of฀adolescents฀who฀smoke฀daily฀in฀ive฀countries฀in฀Germany,฀ the฀reference฀index฀shown฀is฀the฀percentage฀of฀adolescents฀who฀smoke฀regularly฀ [35] Fig. 13.9 ฀฀฀Mean฀per-capita฀ consumption฀of฀tobacco฀in฀ eight฀different฀countries฀ Canada,฀USA,฀Norway,฀ Finland,฀Sweden,฀Austria,฀ France,฀Germany฀[D]฀during฀ the฀period฀1964–1990฀ adapted฀from฀ [114]

13.8 Smoking Bans in Public Buildings and Public Spaces

The฀range฀of฀preventive฀measures฀should฀include฀government฀regulations฀enforcing฀smoking฀ bans฀in฀public฀buildings,฀such฀as฀health฀centres,฀workplaces,฀schools,฀academic฀institutions,฀ waiting฀ rooms,฀ restaurants,฀ businesses฀ and฀ on฀ public฀ transport.฀ Alongside฀ general฀ bans,฀ partial฀bans฀may฀also฀be฀announced฀using฀appropriate฀signage.฀People฀wishing฀to฀smoke฀can฀ be฀referred฀to฀special฀areas,฀a฀partial฀solution฀that฀has฀been฀employed฀in฀the฀USA,฀for฀exam- ple.฀These฀non-smoking฀policies฀can฀be฀supported฀by฀health฀education฀campaigns฀ [102,฀ 103] .฀Comparable฀regulations฀differ฀very฀markedly฀from฀country฀to฀country.฀In฀the฀USA,฀ Australia฀and฀the฀countries฀of฀Northern฀Europe,฀changes฀have฀taken฀place฀as฀a฀result฀of฀ legislation฀and฀general฀attitudes฀towards฀smoking.฀In฀other฀countries,฀the฀regulations฀are฀ considerably฀more฀moderate฀ [104–107] . The฀most฀effective฀means฀of฀achieving฀a฀smoking฀ban฀in฀public฀buildings฀is฀to฀issue฀an฀ absolute฀decision฀on฀the฀matter,฀accompanied฀by฀educational฀programmes,฀dissemination฀ of฀information,฀manager฀training฀and฀provision฀to฀help฀smokers฀achieve฀smoking฀cessation฀ [102,฀103] .฀Two฀studies฀in฀Baltimore฀hospitals฀have฀convincingly฀conirmed฀the฀eficacy฀ of฀this฀approach.฀These฀models฀have฀been฀successfully฀continued฀in฀various฀health฀institu- tions฀in฀the฀USA฀ [108] ,฀and฀instructions฀for฀similar฀campaigns฀are฀now฀available฀on฀the฀ Internet฀ [108] .฀In฀projects฀of฀this฀nature,฀it฀is฀crucial฀that฀the฀organisation’s฀management฀ takes฀responsibility฀and฀talks฀with฀those฀affected฀by฀the฀ban฀to฀provide฀education฀and฀infor- mation.฀It฀has฀also฀been฀found฀that฀only฀comprehensive฀measures฀are฀successful฀in฀the฀ workplace฀ [60,฀109] .฀Stands฀displaying฀“No฀smoking”฀signs฀in฀public฀areas฀are฀minimally฀ successful.฀Similarly,฀discussions฀with฀smokers฀about฀the฀harmful฀effects฀of฀tobacco฀use฀ on฀health฀were฀less฀successful฀than฀face-to-face฀dialogue฀sessions฀between฀smokers฀and฀ non-smokers.฀ According฀ to฀ some฀ studies,฀ successful฀ “No฀ smoking”฀ campaigns฀ in฀ the฀ workplace฀have฀actually฀persuaded฀smokers฀to฀quit฀ [110,฀111] .฀In฀this฀context,฀it฀is฀evi- dently฀important,฀particularly฀in฀Germany,฀to฀issue฀appeals฀to฀the฀medical฀profession฀to฀ ensure฀that฀there฀is฀irst฀a฀reduction฀in฀the฀high฀proportion฀of฀doctors฀who฀smoke฀approxi- mately฀20.฀One฀possibility฀is฀to฀establish฀“smoke-free”฀hospitals,฀an฀approach฀that฀is฀ now฀also฀being฀attempted฀in฀Germany฀e.g.฀the฀“Berlin฀Heart฀Centre”. The฀implementation฀of฀“No฀smoking”฀laws฀is฀only฀useful฀if฀such฀legislation฀is฀sup- ported฀by฀detailed฀regulations฀on฀enforcement฀ [104,฀106] .฀In฀France,฀for฀example,฀the฀ban฀ on฀smoking฀in฀restaurants฀and฀other฀public฀buildings฀is฀largely฀ignored. It฀remains฀to฀be฀established฀whether฀smoking฀bans฀in฀public฀buildings฀will฀bring฀about฀ behavioural฀change฀at฀the฀individual฀level.฀Charitable฀organisations฀and฀anti-smoking฀associa- tions฀must฀certainly฀strive฀to฀achieve฀gradual฀behavioural฀change฀across฀the฀whole฀of฀society,฀ and฀the฀enforcement฀of฀existing฀regulations฀is฀an฀important฀challenge฀that฀must฀be฀solved. A฀reduction฀in฀smoking฀among฀adolescents฀was฀reported฀following฀a฀concerted฀cam- paign฀combining฀restrictions฀on฀smoking฀at฀home฀with฀strict฀bans฀in฀public฀places฀and฀at฀ school.฀The฀study,฀which฀was฀conducted฀among฀17,287฀students฀from฀200฀schools฀over฀30฀ days,฀concluded฀that฀teenage฀smoking฀was฀reduced฀chiely฀through฀restrictions฀on฀smoking฀ at฀home฀and฀in฀public฀places,฀and฀to฀a฀lesser฀extent,฀in฀schools,฀and฀then฀only฀if฀the฀ban฀was฀ strongly฀enforced฀Table฀ 13.4 ฀ [112] .

13.9 Concluding Remarks

A฀ survey฀ of฀ the฀ facts฀ and฀ data฀ presented฀ by฀ the฀ tobacco฀ industry฀ and฀ necessarily฀ •฀ supplemented฀by฀government฀agencies฀to฀ensure฀a฀true฀picture฀reveals฀that฀the฀number฀ of฀adolescent฀smokers฀can฀be฀reduced฀only฀by฀tough฀international฀legislation฀ [113] ฀to฀ regulate฀a฀variety฀of฀issues:฀manufacture,฀trade฀including฀cigarette฀smuggling,฀adver- tising฀and฀distribution฀of฀tobacco฀products฀and฀promotional฀items,฀especially฀to฀young฀ people. In฀particular,฀the฀international฀community฀and฀its฀politicians฀must฀ensure฀that฀economi- •฀ cally฀weak฀countries฀do฀not฀become฀a฀target฀for฀the฀activities฀of฀the฀tobacco฀industry. Every฀single฀day,฀3,000฀adolescents฀in฀the฀USA฀are฀recruited฀to฀the฀ranks฀of฀smokers.฀If฀ •฀ the฀number฀of฀smokers฀is฀not฀reduced฀in฀the฀years฀ahead,฀the฀lamentable฀fact฀is฀that฀10฀ million฀people฀annually฀will฀die฀from฀tobacco-attributable฀causes฀worldwide฀by฀the฀ year฀2025. The฀medical฀profession฀and฀politicians฀must฀not฀stand฀idly฀and฀watch฀this฀trend฀unfold. •฀ References ฀ 1.฀Yach฀D,฀Bettcher฀D฀2000฀Globalisation฀of฀tobacco฀industry฀inluence฀and฀new฀global฀responses.฀ Tob฀Control฀92:206–216 ฀ 2.฀Philip฀Morris฀1997,฀Aug฀23฀Tabakhersteller฀spricht฀von฀den฀Gefahren฀des฀Rauchens.฀Frankf฀ Allg฀Z฀[195],฀1.฀1997 ฀ 3.฀Anonym฀1999฀Bitte฀kaufen฀Sie฀unser฀Produkt฀nicht฀Welt ฀ 4.฀Haustein฀KO฀1999฀Smoking:฀health฀care฀and฀politics฀in฀lux.฀Rauchen:฀Gesundheitswesen฀ und฀Politik฀im฀Wechselspiel.฀Z฀Arztl฀Fortbild฀Qualitatssich฀93:355–361 ฀ 5.฀MacKay฀J,฀Crofton฀J฀1996฀Tobacco฀and฀the฀developing฀world.฀In:฀Doll฀R,฀Crofton฀J฀eds฀ Tobacco฀and฀health.฀Royal฀Society฀of฀Medicine,฀London,฀pp฀206–221 ฀ 6.฀Murray฀C,฀Lopez฀A฀1996฀The฀global฀burden฀of฀disease:฀a฀comprehensive฀assessment฀of฀mor- tality฀and฀disability฀from฀disease,฀injuries,฀and฀risk฀factors฀in฀1990฀and฀projected฀to฀2020.฀ Harvard฀University,฀Boston Table 13.4 ฀฀฀Logistic฀ regression฀ analysis฀ for฀ association฀ of฀ restrictions฀ with฀ 30-day฀ smoking฀ prevalence฀ [112] Odds฀ratio฀95฀CI p฀value Public฀restrictions 0.91฀0.83–0.99 0.03 Total฀home฀ban 0.79฀0.67–0.91 0.001 Some฀home฀restrictions 0.85฀0.74–0.95 0.01 School฀ban 0.99฀0.85–1.13 0.86 Enforced฀school฀ban 0.86฀0.77–0.94 0.001 2logL฀=฀16฀271.0,฀df฀=฀16,฀intracluster฀correlation฀=฀0.038,฀cluster฀variance฀=฀0.131,฀p฀฀0.0001.฀Odds฀ ratios฀are฀adjusted฀for฀school฀grade,฀sex,฀race,฀adult฀smokers฀in฀home฀and฀sibling฀smokers;฀n฀=฀14฀746