ISSN: 2695-2785

Volume 2, No 3 (), pp. -

Doi: -

Dirección Xeral de Saúde Pública Galicia

Tabacco

Abstract: Abstract Tobacco use and passive smoking remain the largest public health problem. The implementation of global and national control measures are the key to achieving the denormalisation of tobacco use in the population. Primary care, and paediatric practices in particular, need to conduct good quality interventions to inform, raise awareness, and protect children from the risks of environmental tobacco smoke (ETS) in their homes and prevent the initiation of tobacco use and new ways of consumption (electronic cigarettes, smokeless tobacco) among the youngest.

Keywords: tobacco; control measures; intervention,; exposure to (ETS); new consumption

INTRODUCTION

The World Health Organization (WHO) states that there is no safe level of exposure to second-hand tobacco smoke and no safe way of tobacco consumption .

Control measures, such as increasing the perception of risk from both tobacco consumption and passive exposure, are key to denormalising tobacco use in society. It goes without saying that the current regulatory framework is a significant step forward.

Creating spaces that are completely free of environmental tobacco smoke (ETS) is the only way to protect individuals from the harmful effects of this habit.

Minors are more exposed to ETS than adults, which makes them more vulnerable and increases their risk of presenting with: low birth weight, sudden infant death syndrome, severe respiratory diseases (asthma, bronchitis, pneumonia), or otitis media, among others. Children exposed to ETS at home are more likely to start smoking than children who are not exposed.

The age of initiation of tobacco consumption is usually between 12-14 years old, with an average period of one to two years required to develop an addiction.

There are many aspects that facilitate the introduction of tobacco consumption among young individuals, the most important of which are advertising, anticipation of adulthood, and peer pressure.

CONTROL MEASURES

If current trends continue unchanged, by 2030 tobacco will have killed more than eight million individuals each year. Tobacco control requires strong political commitment and the involvement of civil society.

Governments try to reduce the harm caused by tobacco by adopting and implementing the provisions set out in the WHO Framework Convention on Tobacco Control, including the provisions that target the reduction of the demand for tobacco, as well as the reduction of tobacco production, distribution, availability, and supply.

1. International legislative measures

WHO FCTC

The WHO Framework Convention on Tobacco Control (WHO FCTC) is the first treaty negotiated under the auspices of the World Health Organization. The WHO FCTC is an evidence-based treaty that reaffirms the right of all people to the highest standard of health. This treaty was developed in response to the globalisation of the tobacco epidemic. (World Health Organization, 2003).

MPOWER

To help countries meet the commitments they made in signing the WHO FCTC, the WHO established MPOWER in 2008, a package of six effective tobacco control policies. (World Health Organization, 2008) .

These are the six policies included in the MPOWER plan: Monitor tobacco use; 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.

2. European legislative measures

2.1- Portuguese legislation

  • Law No. 37/2007 of 14 August. PGDL. Approves the regulations regarding the protection of citizens from involuntary exposure to tobacco smoke and those regarding measures to reduce demand associated with dependency and abandonment of tobacco use. (DRE, 2007)

    • Law No. 109/2015 of 26 August. First amendment to the Law No. 37/2007 of 4 August, transposing Directive 2014/40/EU.

    • Law No. 63/2017 of 3 August. Second amendment to the Law No. 37/2007 of 14 August. Regulation of new smokeless tobacco products.

  • National Report 2013: Portugal. National focal point, Lisbon, May 2014. (Santos & Duarte, 2014) .

2.2 - Spanish legislation

  • Law 28/2005 of 26 December regarding health measures with respect to tobacco addiction and regulating sales, supplies, consumption, and advertising of tobacco products, and its subsequent amendments, the most important of which was made five years later, in which smoke-free spaces were expanded (Law 42/2010). (Boletín Oficial del Estado, 2005) .

  • Changes to the legislation:

    • Law 42/2010 of 30 December, amending Law 28/2005 of 26 December, on health measures against smoking and regulating sales, supplies, consumption, and advertising of tobacco products.

    • Law 3/2014 of 27 March, which modifies the revised text of the General Law for the Protection of Consumers and Users and other complementary laws, approved by the Royal Legislative Decree 1/2007 of 16 November.

    • Royal Decree-Law 17/2017 of 17 November, which amends Law 28/2005 of 26 December, on health measures against smoking and regulating sales, supplies, consumption, and advertising of tobacco products, transposing the Directive 2014/40/EU of the European Parliament and of the Council of 3 April 2014.

    • Royal Decree 579/2017 of 9 June, regulating certain aspects of the manufacture, presentation and marketing of tobacco and related products.

EPIDEMIOLOGICAL EVIDENCE

The Global Youth Tobacco Survey (GYTS) -- (Global Youth Tabacco Survey Collaborative Group, 2002) (World Health Organization, 2016) funded by the U.S. Centers for Disease Control and Prevention, the Public Health Agency of Canada, the U.S. National Cancer Institute, the United Nations Children’s Fund (UNICEF), and the WHO’s Tobacco Free Initiative, gives us an overall view of tobacco consumption in the youngest population.

According to the Spanish National Health Survey (ENSE-2017), 22% of the population over the age of 15 smokes daily, with 17.56% in the 15-24 age group and a prevalence of 19.96% in men and 15% in women. This survey was conducted by the Spanish Ministry of Health, Consumer Affairs, and Social Welfare in collaboration with the Spanish National Statistics Institute.

https://www.mscbs.gob.es/estadEstudios/estadisticas/encuestaNacional/encuesta2017.htm

The ESTUDES-2016 survey, on drug use in secondary education, was carried out by the Spanish National Drug Plan in high school students from 14 to 18 years old. It was found that tobacco was the second most consumed substance by adolescents (alcohol was the substance with the highest prevalence). 19.8% of 14 year-old students admitted having smoked tobacco in the last 12 months, a prevalence that almost doubled among 16 year-old students (36.7%). Figures increase with age: the prevalence among 18-year-olds was 55.6%.

http://www.pnsd.mscbs.gob.es/profesionales/sistemasInformacion/sistemaInformacion/encuestas_ESTUDES.htm

ADRESSING TOBACCO ADDICTION

Clinical practice guidelines recommend that all health professionals ask about and record the patients’ relationship with tobacco at least once a year and advise smokers to quit.

Tobacco interventions in paediatric practices must include both health advice on smoking cessation to parents/guardians and advice on passive exposure to tobacco smoke in clinical practice.

The objectives of this paediatric intervention include the following:

  • 1) To increase the perception of risk associated with tobacco consumption and passive smoking.

  • 2) To avoid, or otherwise delay, the age of onset of consumption of tobacco, tobacco products, and electronic cigarettes.

  • 3) To help young individuals who have already started smoking to quit.

1. Counselling

This intervention only takes 2-3 minutes and is a cost-effective practice.

Tobacco counselling for smokers should be clear, brief, firm, timely, personalised, and focused on highlighting the benefits of quitting smoking and the risks of continuing to smoke, thus encouraging the smoker to change and consider quitting. Counselling is more effective if accompanied by an information leaflet: "The best thing you can do for your health is to stop smoking".

In the case of adolescents, the aim should be to avoid the onset, so the counselling has to be focused on highlighting the benefits of not taking up smoking by adapting the counselling to the individual’s current interests. Usually, in these age ranges, warning of the health risks of tobacco use is not a message that resonates with young people, because at this point in life in general, this issue does not concern them or they do not feel that it is relevant to them.

Personalising the counselling provided to young individuals who attend the consultation by relating physical appearance to tobacco consumption may be reason enough for non-initiation, which makes counselling a preventive tool.

Individuals who smoke occasionally need to realise that smoking causes addiction, which means a loss of freedom. Therefore, they need to be provided with information to help them quit at this early stage, before addiction sets in. In these cases, the intervention will be carried out using cognitive-behavioural strategies (Fiore MC, Jaén CR, Baker, 2008)).

In adolescents who are already dependent, it may be necessary to conduct interventions that include pharmacological treatment (NICE, 2018) .

Interventions targeting parents and/or adolescents should always be documented in the clinical record.

1.1 Counselling - Passive smoking

Children do not have a "choice" about whether or not they want to be exposed to tobacco smoke. This decision rests with the adults responsible for them. It is therefore imperative that they are aware of the health risks of such exposure. It may be safe to say that the potential health risks for smokers are the same as those that result from exposure to passive smoking (even though the incidence of smoking-related conditions in passive smokers is lower), in addition to the aforementioned specific conditions caused in children in their first years of life.

This is why it is important to incorporate passive smoking health advice into paediatric consultations by providing personalised, relevant information to parents, as minors are particularly vulnerable to exposure to environmental tobacco smoke.

Clinicians should always ask and record if anyone in the household smokes, congratulate them if they are not exposed to ETS (positive reinforcement), and recommend them to not allow anyone smoke inside the house.

If anyone in the family smokes, they should be informed of the risks of passive smoking for their loved ones.

Strategies should be provided and the smoker should be advised not to smoke at home.

1.2. Recommendationes

  • 1) Making parents aware of the importance of not exposing their children to environmental tobacco smoke..

  • 2) Denormalising the consumption of tobacco in the family environment, with parents and guardians setting a positive example regarding tobacco.

  • 3) Promoting tobacco cessation among adults living with minors.

  • 4) Incorporating health advice on tobacco for young individuals who attend the consultation from the age of onset of consumption (12-14 years old) by adapting the intervention to the profile of each child.

  • 5) Documenting the counselling in the medical record.

2. Frequently asked questions in daily practice

Throughout the years, myths have been built up around tobacco and have been spreading among the population. Healthcare professionals must know how to respond to these myths during consultation. There is only one fact that has been proven by science: tobacco smoking and passive exposure causes disease and death.

In the present document, many myths (related to economy, society, freedom) are addressed (Córdoba & Samitier, 2009) .

3. New ways of consumption

The consumption of conventional tobacco, tobacco products, and electronic cigarettes are harmful to health, since they all contain nicotine, a highly addictive substance with known cardiovascular effects that has been scientifically proven to be harmful to the body, as well as other potentially harmful substances (Ministerio de Sanidad, Consumo y Bienestar Social – España, 2014).

The implementation of regulations on tobacco consumption has had a denormalising effect on its use in society, which has led to a decrease in consumption, because many smokers are quitting and the younger population is not taking up smoking. Faced with this situation, the tobacco industry has introduced different products to try to alleviate the decline in profits and attract new consumers. This industry is offering consumers new products with the message of a lower risk to their health if they choose these forms of consumption. However, there is currently no scientific evidence to support these claims.

The first products to appear were devices capable of releasing nicotine, known as electronic cigarettes, which purportedly posed a lower risk to health and were even considered to be a tool for smoking cessation.

The WHO’s position is clear: “electronic cigarettes are devices that maintain or may generate an addictive disorder, and it has not been scientifically proven that electronic cigarettes may be an aid in the process of smoking cessation (World Health Organization, 2003)” .

The Spanish Ministry of Health has recently published a brief report on the pathologies that have occurred in users of electronic cigarettes in the USA.

The next products to appear were smokeless or non-combustion cigarettes (heat-not-burn tobacco). These devices contain tobacco, but, instead of burning it like conventional cigarettes, they heat it up, reaching temperatures of 350°. They produce steam, which would make them similar to electronic cigarettes. Based on chemical studies, the sidestream of tobacco smoke (produced at about 300-400°) contains a higher concentration of toxic elements than the main stream of smoke (Ayesta, García-Blanco, & Rodríguez-Lozano, 2014) .

Currently, until the effects of non-combustion tobacco are thoroughly studied, it is not possible to ensure that they are less harmful. However, it is completely safe to say that it is potentially addictive and toxic (World Health Organization, 2003) .

The latest device to appear was the JUUL system, which is causing a great impact among young people in the U.S. It has such a sleek design that it has been dubbed “the iPhone of e-cigs”, it looks like a pen-drive and may be charged in any USB port (Organización Médica Colegial Española, 2018).

Not consuming traditional tobacco, tobacco products, or consuming nicotine by using more recent technologies is the key recommendation to prevent health problems associated with tobacco consumption or passive exposure to tobacco smoke, because its toxicity and harmful effects have been proven scientifically (Ministerio de Sanidad, Consumo y Bienestar Social, 2018).

RESOURCES

Report on electronic cigarettes: current situation, available evidence and regulation

Acknowledgment

This publication has been possible to the cooperation program Interreg VA España-Portugal POCTEP - RISCAR 2014-2020.

http://www.poctep.eu

RINSAD

Journal of Childhood and Health (RINSAD), ISSN-L: 2695-2785, is a the collaboration between administrations Portugal, Galicia, Castilla y León, Extremadura and Andalusia within the project Interreg Spain-Portugal RISCAR ‚ and aims to disseminate scientific articles related to child health, contributing to researchers and professionals in the field a scientific basis where to know the advances in their respective fields.

The RISCAR project is co-financed by the European Regional Development Fund (ERDF) through the Interreg Program V-A Spain-Portugal (POCTEP) 2014-2020, with a total budget of € 649,699.

Journal Interreg Spain - Portugal RISCAR with the Universidad de Cádiz ‚ and the Departamento Enfermerí­a y Fisioterapia de la Universidad de Cádiz .

License Creative Commons Atributtion-NonCommercial-ShareAlike 4.0 Internacional.

References