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1. Tobacco
1.1. Individual interventions
An individual approach to smoking
cessation includes pharmacotherapy and behavioral therapy. Only 3% of smokers
manage to quit smoking using will power alone. Success depends to a great
extent on motivation, but a combination of pharmacotherapy and behavioral
therapy probably yields best results. Nicotine replacement therapy (NRT) in
form of patches, chewing gum, lozenges, inhalers and nasal sprays helps
relieve the withdrawal symptoms that prevent many smokers from quitting. It
contains nicotine, but does not contain thousands of other harmful substances
found in cigarettes and snuff.
The non-nicotine pharmacotherapy
includes several drugs from different categories. Two of the most promising
are bupropion and varenicline. They are both prescription drugs approved by
national authorities of some countries to help patients stop smoking.
Bupropion is an antidepressant drug that reduces withdrawal symptoms and
lessens the urge to smoke. Varenicline, recently approved both in Europe and
USA, is a partial nicotine agonist that prevents the nicotine-withdrawal
symptoms, and eliminates the reward from smoking.
Certain moods, times of the day,
or activities may present strong triggers for craving a cigarette.
Pharmacotherapy is not a cure for these smoking triggers. Furthermore, the
motivation to quit smoking determines the success rate of smoking cessation
to a large extent. Some studies found that the integration of behavioral
therapy can increase the quitting rate by another 50-100%. Psychosocial
interventions are helpful at all phases of tobacco addiction treatment, not
only as a first-line intervention. There is a wide range of psychosocial
treatment options, including counseling via internet and telephone, as well
as individual and group counseling.
1.2. Collective interventions –
tobacco control in the EU
Collective interventions geared
towards the reduction of tobacco related harm can be categorized as follows:
·
measures
to reduce the demand for tobacco products (price, taxation);
·
measures
to reduce exposure to environmental tobacco smoke
(smoking bans in public places);
·
measures
to limit tobacco industry advertising, promotion and sponsorship; and
·
measures
to raise awareness about the addictive nature and health hazards of tobacco
use
Curbing tobacco use is a longstanding
EU health priority. The EU has been actively contributing to the reduction of
tobacco consumption for more than twenty years. This contribution has evolved
from prevention, training and research within the scope of the fight against
cancer, to a broad strategic tobacco control approach. The current EU-wide
efforts are based on four mutually reinforcing pillars:
·
legislative
measures, based on the Community Treaties as well as more specific, secondary
legislation;
·
support
for Europe-wide and cross-national smoking prevention and cessation
activities, financed via action programmes and the Community Tobacco Fund;
·
mainstreaming
of tobacco control into a range of other Community policies; and
·
ensuring
the Community’s achievements also have
an impact outside the EU region, by fostering international co-operation and
taking on a major role in tobacco control at a global level.
EU action focuses on supporting prevention, collaboration between
Member States, and research. The quest for a smoke free EU also forms part of
the Environment and Health Action Plan, through which passive smoking is now
more actively tackled.
Legally, these efforts are firmly
grounded in the Community Treaties and supported further by a range of specific regulations.
The legal competencies of the EU enable it to make some unique contributions
to tobacco control in Europe, and indeed globally. The WHO Framework
Convention on Tobacco Control (FCTC), which all Member States and the
Community have signed, has been a significant factor in the further
advancement of tobacco control at EU and Member State level. Within the
Treaties of the Community, articles 152 and 95 EC provide the legal base for EU policy and
action in the area of tobacco control. These articles are concerned
respectively with public health and internal market issues. Through the
application of these two articles, a range of more specific measures and
agreements have been developed to support the EU’s efforts in the area of
tobacco control.
The provisions in the Treaty have
been given force through a range of secondary legal measures to support
tobacco control. Together, they underpin and complement the Community’s
action, including a range of smoking prevention and cessation activities. Binding legal measures
include Directives on:
·
the
advertising and sponsorship of tobacco products;
·
the
structure and rates of excise duty applied on manufactured tobacco;
·
the
manufacture, presentation and sale of tobacco products;
·
television
broadcasting, banning the advertising of tobacco products; and
·
minimum
safety and health requirements for the workplace.
Non-binding legal measures
include:
1) a Council Recommendation on
the prevention of smoking and on
initiatives to improve tobacco control. This recommendation pays particular
attention to measures restricting youth access to tobacco; and
2) a Resolution on banning
smoking in public places. Since the adoption of the resolution in 1989,
Member States’ governments have developed their own specific action to
implement this resolution, and have done so at their own pace.
International organisations
The WHO Framework Convention on
Tobacco Control (FCTC) is the first-ever global health treaty providing a
comprehensive tobacco control framework (WHO, 2005). The FCTC objective is 'to
protect present and future generations from the devastating health, social,
environmental and economic consequences of tobacco consumption and exposure
to tobacco smoke.' The EU Council approved the FCTC in
June 2004, and subsequently ratified it on 30 June 2005.
Significant measures to reduce
the demand for tobacco, that are supported by the FCTC include:
price and tax measures;
protection from exposure to tobacco
smoke, particularly in workplaces, public transport and indoor
public places;
regulation of the contents of
tobacco products;
regulation of tobacco product
disclosures;
packaging and labeling of tobacco
products, requiring large health warning labels and prohibiting the use of
deceptive labels such as "light", "low tar", and
"mild";
education, communication,
training and public awareness;
tobacco advertising, promotion
and sponsorship. Countries are to undertake a comprehensive ban on tobacco
advertising, promotion and sponsorship within five years of ratifying the treaty
if their constitutions allow this. If there are constitutional constraints,
countries are required to put restrictions in place; and
demand reduction measures
concerning tobacco dependence and cessation.
The FCTC also supports measures
to reduce the supply of tobacco. These include:
1. illicit trade in tobacco
products (smuggling);
2. sales to and by minors, and
3. provision of support for
economically viable alternative activities.
By signing the Treaty, countries
also commit themselves to take supportive measures at national level. Key
examples of these measures are:
the establishment of a national
coordinating mechanism or focal point for tobacco control;
the inclusion of tobacco
cessation services in national health programmes, and
promoting the participation of
NGOs in the development of national tobacco control programmes.
Under the UN Charter, identifying
solutions to international social and health problems falls within the remit
of the Economic and Social Council (ECOSOC). Their Resolution 2004/62 on Tobacco Control supports the
WHO Framework Convention on Tobacco Control. It urges UN Member States to
strengthen tobacco control measures and programmes.
On 7 February 2008 WHO released a
new Report on “Global Tobacco Epidemic” showing that while progress has been
made, not a single country fully implements all key tobacco control measures,
and outlined an approach that governments can adopt to prevent tens of
millions of premature deaths by the middle of this century. In this new
report which presents the first comprehensive analysis of global tobacco use
and control efforts, WHO finds that only 5% of the world’s population live in
countries that fully protect their population with any one of the key
measures that reduce smoking rates. The report also reveals that governments
around the world collect 500 times more money in tobacco taxes each year than
they spend on anti-tobacco efforts. It finds that tobacco taxes, the single
most effective strategy, could be significantly increased in nearly all countries,
providing a source of sustainable funding to implement and enforce the
recommended approach, a package of six policies called MPOWER. The six MPOWER
strategies are:
Monitor tobacco use and prevention
policies
Protect people from tobacco
smoke
Offer help to quit tobacco use
Warn about the dangers of tobacco
Enforce bans on tobacco
advertising, promotion and sponsorship
Raise taxes on tobacco.
The report also documents the
epidemic's shift to the developing world, where 80% of the more than eight
million annual tobacco-related deaths projected by 2030 are expected to
occur. The global analysis, compiled by WHO with information provided by 179
Member States, gives governments and other groups a baseline from which to
monitor efforts to stop the epidemic in the years ahead. The MPOWER package
provides countries with a roadmap to help them meet their commitments to the
widely embraced global tobacco treaty known as the WHO Framework Convention
on Tobacco Control, which came into force in 2005. Other key findings in the
report include:
Only 5% of the global population
is protected by comprehensive national smoke-free legislation and 40% of
countries still allow smoking in hospitals and schools;
Only 5% of the world’s population
lives in countries with comprehensive national bans on tobacco advertising
and promotion;
Just 15 countries, representing
6% of the global population, mandate pictorial warnings on tobacco packaging;
Services to treat tobacco
dependence are fully available in only nine countries, covering 5% of the
world’s people;
Tobacco tax revenues are more
than 4000 times greater than spending on tobacco control in middle-income
countries and more than 9000 times greater in lower-income countries.
High-income countries collect about 340 times more money in tobacco taxes
than they spend on tobacco control.
2. Alcohol
Risk reduction strategies include
a set of measures in a jurisdiction or society aimed at minimizing the health
and social harms that result from alcohol consumption. They are implemented
by alcohol policies, which include authoritative decisions that are made by
governments through laws, rules and regulations, coming from the legitimate
purview of legislators and other public interest group officials, and not from
private industry or related advocacy groups. In the context of public health
the central purpose of alcohol policies is to serve the interests of public
health and social well-being through their impact on health and social
determinants, such as drinking patterns, the drinking environment, and the
health services available to treat problem drinkers.
Alcohol is a major economic
commodity that is associated with substantial governmental tax receipt and
Europe can be considered the centre of the global alcohol industry, acting as
both the largest market and the major producer of alcoholic drinks.
Therefore, it may be appropriate to recall that the trade in alcohol in the
whole European Union accounts for 1.3% of all exports and 0.3% of all
imports, thereby contributing €8.9 bn to the goods account balance, with such
trade not necessarily affected by European and domestic policy to reduce the
harm done by alcohol.
Maintaining the relative price of
alcohol
When other factors are held
constant, the more affordable alcohol is, the more it is consumed; and the
less affordable it is, the less it is consumed. The way drinkers respond to
and compensate for price changes is complex, because of the possibilities for
substitution. Drinkers tend to shift to more expensive beverages if relative
prices decrease, either within the same beverage category or across beverage
categories. If prices are raised, they both reduce overall consumption but
also shift to cheaper beverages. Heavy drinkers tend to buy the cheaper products
within their preferred beverage category. The impact of an increase in
alcohol price is stronger in the longer term than it is in its immediate
effects. From a public policy perspective, it is the long term effects,
taking into account alcohol’s dependence producing properties that are more
important. Young people are particularly sensitive to price. Policies that
increase alcohol prices have been shown to reduce the proportion of young
people who are heavy drinkers, to reduce underage drinking, and to reduce per
occasion binge drinking. Higher prices also delay intentions among younger
teenagers to start drinking and slow progression towards drinking larger
amounts. Heavy drinkers are also sensitive to price, with higher alcohol
taxes or prices leading to reductions in deaths from liver cirrhosis,
fatality rates from traffic crashes, and reduced rates of crime, including
assault, violence related injury, homicide, family violence, and child abuse
and other violence towards children.
While it may be predicted that
the revenues from tax on alcohol depends on the total amount of alcohol drunk
in a country, the evidence suggests that this is not the case. There is no
apparent correlation between the revenue from alcohol-specific taxes (as a %
of government revenue or % of GDP) and per capita consumption. The best
predictors of the importance of alcohol-specific taxes are unsurprisingly the
average alcohol tax rates, which relate very closely to the income from
alcohol taxes.
Managing the sale of alcohol
The smaller the number of outlets
for alcoholic beverages, the greater the difficulty in obtaining alcohol, a
situation that is likely to deter alcohol use and problems. A number of
studies have indicated that although changing either hours or days of alcohol
sale can redistribute the times at which many alcohol related crashes and
violent events related to alcohol take place, it does so at the cost of an
overall increase in problems. Around-the-clock opening in Reykjavik, for
instance, produced net increases in police work, in emergency room admissions
and in drink-driving cases.
There is also evidence that
restricting days and hours of sale reduces problems. In the 1980s Sweden
re-instituted Saturday closing for spirits and wine off-premise sales after
studies showed that Saturday sales were associated with increased rates of
domestic violence and public drunkenness . Some 20 years later, when Saturday opening of government
alcohol stores was re-instituted, there was a 3.6% increase in alcohol sales.
Almost all countries legally
restrict alcohol sales to minors. There is very strong evidence that changes
in minimum drinking age laws can substantially effect youth drinking and
alcohol-related harm, particularly road traffic accidents; however, the full
benefits of a higher drinking age are only realized if the law is enforced.
Advertising controls
Eight US-based well designed
longitudinal studies and one Belgian well designed longitudinal study show
that the volume of advertisements and media exposure increase the likelihood
of young people starting to drink, the amount they drink, and the amount they
drink on any one occasion. There have been no published longitudinal studies
that do not find such an effect. These findings are similar to the impact of
advertising on smoking and eating behaviour. It is difficult to study the
relationship between expenditure on commercial communications, or whether or
not there are bans on alcohol advertisements in a jurisdiction and drinking
by young people. Where this has been done, some studies have found that
increased expenditure on advertising is associated with increased
alcohol-related harm amongst young people, and that total bans have reduced
alcohol-related harm, whereas others have not. In general, later studies
seem to have found more of an effect of commercial communications. The
evidence would thus show that there is a need to specify the extent to which
alcohol advertising in certain categories of media and publications is
allowed, and it would suggest that, as is the case with tobacco,
consideration should be given to the prohibition of advertising of alcohol
products on television and radio and in specified certain print media. There
are good examples of regulations on alcohol marketing in some countries.
France’s Loi Evin is one such model which bans most advertising and
sponsorship and restricts permitted advertising to description of the product
without any of the messages which make advertising particularly attractive to
younger people. When the Loi Evin was challenged in the European Court of
Justice, it was upheld, noting that it is in fact undeniable that advertising
acts as an encouragement to consumption; the French rules on TV advertising
are appropriate to ensure their aim of protecting public health; and they do
not go beyond what is necessary to achieve such an objective .
Setting and controlling blood
alcohol levels.
Establishing a maximum
blood-alcohol level (BAL) for driving is a well-established and widely
diffused drinking-driving countermeasure. Over the years, the level
specified as maximum has been lowered in a number of countries, and is as low
as zero or 0.2g/l in a number of countries, and 0.5g/l or lower in most
countries in Europe. Both establishing a BAL and lowering it are effective
in reducing drinking-driving casualties (Anderson and Baumberg 2006). There
is also convincing evidence that both intensive random breath testing, where
police regularly stop drivers on a random basis to check their BAL, and
sobriety checkpoints, where all cars are stopped and drivers suspected of
drinking driving are breath-tested, reduce alcohol-related injuries and
fatalities.
Setting lower BALs (including a
zero level) for young or novice drivers; administrative driver's license
suspension for a driver caught with a positive BAL particularly in legal
systems in which a criminal drinking-driver case may be delayed or
successfully fought by a defence lawyer; and the use of an ignition
interlock, a mechanical device which does not allow a car to be driven by a
driver with a BAL above a low level, for reducing repeat infractions by
convicted drinking drivers are all effective in reducing drink driving
casualties.
Finally, there are a number of
measures that have shown to be not effective in reducing drinking and driving
(Anderson and Baumberg 2006). These include designated drivers and ride
services, such as the BOB campaign. No study has evaluated whether the use of
designated drivers actually decreases alcohol-related motor vehicle-related injuries
(Ditter et al, 2005). However, although the BALs of designated drivers are
generally lower than those of their passengers they are still often higher
than the legal limit for drinking and driving. Further, an increase in
passenger alcohol consumption is often found when a designated driver is
available.
Educational programmes and information campaigns
Whilst the provision of
information and persuasion to reduce alcohol related harm might seem
appealing, particularly in relation to younger people, it is unlikely to
achieve sustained behavioural change in an environment in which many
competing messages are received in the form of marketing and social norms
supporting drinking, and in which alcohol is readily available. Many careful
systematic reviews have evaluated school based education which aimed to
reduce alcohol related harm, and found that classroom based education is not
an effective intervention to reduce alcohol related harm; although there is
evidence of positive effects on increased knowledge about alcohol and in
improved attitudes, there is no evidence for a sustained effect on
behaviour.
In general, public information
campaigns are also an ineffective antidote to the high quality, pro-drinking
messages that appear far more frequently in the media. Further, counter
advertising (a variant of public information campaigns which provides
information about a product, its effects and the industry that promotes it in
order to decrease its appeal and use) has inconclusive effects. Whilst
drinking guidelines have been used in a number of countries, there have been
no evaluations that find an impact of these guidelines on alcohol related
harm . The United Kingdom’s ‘sensible drinking guidelines’ when relied upon
as a key prevention strategy in a liberalizing policy environment failed to
deter increases in alcohol consumption. The exception to this evidence of
inefficacy is the evidence for the impact of mass media campaigns to reduce
drinking and driving, particularly in jurisdictions with strong policies in
place concerning drinking and driving.
Drinking context
Licensed drinking environments
are associated with drunkenness, drink-driving and problem behaviours such as
aggression and violence, with some licensed premises being associated with a
disproportionate amount of harm. Nearly all evaluations in training bar staff
in responsible beverage service when backed up with enforcement have
demonstrated improved knowledge and attitudes among participants, although
this wears off over time. These studies have also shown some effects on
serving practices, but not always. Whilst servers are usually willing to
intervene with customers who are visibly intoxicated, they generally will not
intervene with individuals solely on the basis of the customer’s estimated
blood alcohol concentration (BAC) or number of drinks consumed. In terms of
the effects on customer intoxication, several studies have found that server
training results in lower BAC levels of customers generally and fewer
customers with high BAC levels. Studies of the impact of adhering to bar
policies for avoiding intoxication have also found modest effects in reducing
heavy consumption and high risk drinking, but were not as successful as
originally expected. The impact of responsible beverage service is greatly
enhanced when there is active, but ongoing enforcement of laws prohibiting
sale of alcohol to intoxicated customers.
Community based prevention
programmes can be effective in reducing drinking and driving, alcohol related
traffic fatalities and assault injuries. Community mobilization has been used
to raise awareness of problems associated with on-premise drinking, develop
specific solutions to problems, and pressure bar owners to recognize that
they have a responsibility to the community in terms of such bar-related
issues as noise level and customer behaviour. Evaluation results from
community mobilization approaches as well as documentation from grassroots
projects suggest that community mobilization can be successful at reducing
aggression and other problems related to drinking in licensed premises.
Advice and treatment
Healthcare-based interventions
for hazardous and harmful alcohol consumption reduce alcohol consumption, as
well as demonstrating reductions in alcohol related problems and
alcohol-related mortality. The community based Malmö study, undertaken during
the 1970s, demonstrated that under the right conditions, the effects can be
dramatic. An intervention for heavy drinkers resulted in half the deaths that
occurred in the control group without the intervention at six year follow-up.
There is extensive evidence that shows the effectiveness and
cost-effectiveness of opportunistic screening and brief interventions for
persons with hazardous and harmful alcohol use in the absence of severe
dependence. If these programs were widely adopted in health care systems,
the population impact on excessive drinking could be significant. For
people with more severe alcohol dependence and related problems, a wide
variety of specialized treatment approaches have been evaluated, including
behavioural, psychosocial, and pharmacological interventions of varying
intensities in both community and residential settings (Miller and Wilbourne
2002). The evidence shows that individuals exposed to these treatments,
especially when delivered in a timely manner, achieve better outcomes than
those not receiving treatment. Further, for the average person, the
effectiveness of these treatments tends to be comparable regardless of
intensity, modality or setting.
Relevant alcohol policy
documents
·
Television
Without Frontiers Directive
 http://europa.eu.int/eur-lex/en/consleg/pdf/1989/en_1989L0552_do_001.pdf
·
Commission
Recommendation on maximum permitted blood alcohol content, 2001
http://europa.eu.int/eur-lex/lex/LexUriServ/LexUriServ.do?uri=CELEX:32001H0115:EN:HTML
·
Council
Recommendation on the drinking of alcohol by young people, in particular
children and adolescents, 2001
http://europa.eu/scadplus/leg/en/cha/c11564.htm
·
European
Commission Road Safety Action Programme 2003-2010
http://europa.eu/scadplus/leg/en/lvb/l24257.htm
·
European
Commission Communication on EU alcohol strategy, 2006
http://ec.europa.eu/health/ph_determinants/life_style/alcohol/documents/alcohol_com_625_en.pdf
·
European
alcohol and health forum, 2007
http://ec.europa.eu/health/ph_determinants/life_style/alcohol/alcohol_charter_en.htm
Projects funded under the Public Health Programme
2003-2008
·
PHEPA:
Primary Health Care European Project
http://www.phepa.net
·
EUROCARE
– Alcohol Policy Network in the Context of a Larger Europe: Bridging the Gap
http://ec.europa.eu/health/ph_projects/2003/action3/action3_2003_02_en.htm
·
ELSA
– Enforcement of national Laws and Self-regulation on advertising and
marketing of Alcohol
http://ec.europa.eu/health/ph_projects/2004/action3/action3_2004_16_en.htm
Research projects on alcohol
·
Genomics,
mechanism and treatment of addiction
http://cordis.europa.eu/
·
European
Prospective Investigation into Cancer, Chronic Diseases, Nutrition and Lifestyle
http://cordis.europa.eu/fetch/
·
DRUID:
Driving under influence of drugs, alcohol and medicine
http://cordis.europa.eu/eoi/dsp_details.cfm?ID=2638
·
DG
SANCO pages on Alcohol
http://ec.europa.eu/health/ph_determinants/life_style/alcohol_en.htm
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