The World Health Organisation
Europe Partnership Project
to reduce Tobacco Dependence (PPTD)
he WHO Partnership Project to reduce experience of the project to date and identification of ducts and treatment products that best serve public tobacco dependence was launched early in major needs, a number of new deliverables are health. The conferences will be followed with the pre- T 1999. The Project is operational in four planned for implementation during the year 2000, paration and publication of WHO/EU/expert endorsed
target countries, with the objective of reducing grouped under the existing five activity headings. best practice recommendations and guidelines for the tobacco related death and disease among tobacco regulation and treatment products that promote dependent smokers. The Project has implemented a Activities
public health. Advocacy and regular reporting at the number of significant deliverables during its first year target country level on implementation should follow of operation and it has laid the groundwork for secure the publications of the recommendations. The activity It is proposed to continue with five main activity areas, expansion and development during the year 2000 and will provide technical support that can feed into the building into these activities new initiatives and deli- preparation for the treatment protocol for the Framework Convention on Tobacco Control. It is Four target countries were chosen for the first year of planned to undertake a search of the tobacco indus- Activity 1 - Tracking adult’s smoking status and
implementation of the project, France, Germany, try documents released through litigation and prepare their intention to change
Poland and the United Kingdom. Considerable tech- a report on the tobacco industry’s views on treatment The aim of this activity is to develop a gold standard nical and political successes have been achieved in for survey content and methodology, tracking adult’s these countries. It is planned that the project will be • Expected deliverables
smoking status and their intention to quit. The goal is expanted to other countries in the European region in 1. WHO/EC/expert – endorsed ‘best practice’ recom- to ensure that the gold standard survey content and mendations and guidelines for regulations of treat- methodology is incorporated into ongoing and ment products that promote public health planned country based and European surveys that During the first year of the Project’s operation, the 2. National report on each target country on progress include questions about tobacco use and intentions political environment has changed, partly as a result in adopting best practice recommendations of the project. The changed environment has increa- 3. Widespread dissemination of findings and advoca- • This will entail the following:
sed the importance of the Project and created a 1. Gold standard for survey methodology and survey number of new strategic openings for the Project. 4. Review and report of tobacco industry documents content for use in target countries, and at European • Fast tracking implementation of the Framework 2. Dissemination of gold standard throughout scienti- Convention on Tobacco Control, the world’s first Activity 3 - Expanding smoke free places
Creating business forum for health
3. Advocacy for data collection in four target countries • European responsibility, through the WHO A publication is being prepared to describe the Committee for a Tobacco Free Europe, to prepare a legal basis for smoke free workplaces in the four 4. Periodic reviews of published and unpublished protocol on treatment of tobacco dependence for the target countries. Conference are being organized in the UK and Berlin to build European consensus on 5. Use of results to advance policy • Formal acceptance by Poland to host the 2001 policies to promote smoke free work environments. 6. Report to 2001 ministerial conference ministerial conference on tobacco, an important A new activity will be the development and launch milestone in the process of adoption of the of ‘Business Forum for Health’ and preparation of Activity 2 - Regulating tobacco products and
20 examples of good practice and case study. Until • The convening of a NGO/technical conference, tobacco dependence treatment products.
June 2001, the time of the Ministerial and NGO incorporating the third European Conference on The implementation of this activity achieved conside- conferences on tobacco or health, it is proposed rable success, with the regulatory conferences that that the Business Forum for Health will focus on • Global responsibility of the European Office for WHO took place in Helsinki, October 1999. The confe- the issue of Quitting Smoking. An integral part of for the topic of the treatment of tobacco dependence. rences will lead to a report and summary of the expe- the launch will be involvement of the Forum with On the basis of the changed political environment, the rience and practice for the regulation of tobacco pro- AN ACTION FINANCED BY THE EUROPE AGAINST CANCER PROGRAMME
The WHO Europe Partnership Project
to reduce Tobacco Dependence (PPTD)
the artists project (see activity 5). Companies who signup to the Business for Health Forum will be able to Ireland - Consensus achieved on
purchase the original works of art and also the posterrights to them, for use in their workplaces, and in otherways to be defined. Minimum Standards Smoke-free
Activity 4 - Promoting the implementation of evi-
dence-based treatment

Policy for Irish Hospitals
Activity 4 includes the development of the health andeconomic consequences of smoking (HECOS) modeland the preparation of draft evidence based recom- he devastating affects of smoking on health are well hospitals. This development was viewed as an essential mendations on the treatment of tobacco dependence T known to all healthcare workers. It is the single most prelude to the Network’s participation in Phase Two of
for health care systems in Europe. An application was important factor in premature mortality and some major the EU Project- European Smoke-free Hospital Network. made to place Nicotine Replacement Treatments on diseases. Not surprisingly therefore, one of the initiatives the WHO list of essential drugs. Further data is requi- adopted by the Irish Health Promoting Hospitals (HPH) The core principles that underpin the minimum standards red and the application is to be re-submitted. The Network is the Smoke-free Hospitals Initiative.
smoke-free policy are the need to protect people from activity will provide technical support that can feed passive smoking and to provide support to smokers who into the preparation for the treatment protocol for the The Irish HPH Network, launched in 1997, is a participant wish to stop smoking. The policy acknowledges that all Framework Convention on Tobacco Control. Funding in the WHO European HPH Network that aims to employees, patients and visitors have a right to a smoke- for a WHO European publication on treatment of promote facilitate and assist hospitals with the integra- free environment, that non-smoking should be the norm tobacco dependence will be met through voluntary tion of a health promotion philosophy and culture in the in all hospital premises unless specifically designated hospital setting. This movement is consistent with the otherwise, that the right of the non-smoker to breathe Other new deliverables include workshops for senior World Health Organisation’s setting approach to health clean air takes precedence at all times and the need for national policy makers on treatment systems, deve- promotion and utilises the Ottawa Charter as a frame- flexibility should be recognised in a number of restricted lopment of arguments for reimbursement for treat- work for action. Until now participating networks have ment of tobacco dependence, public health review of determined their own specific criteria for participation, the use of treatment products for temporary abstinen- however, the implementation of a smoke-free policy as a The aims of this policy are clearly outlined in a position ce and reduction in the use of tobacco products and set criterion of membership seems apparent.
statement at the forefront of the document, which states: legal assessment of clinical liability of practitioners • A minimum standards Smoke-free Hospital policy aims failing to provide treatment for tobacco dependence. As the hospital is both a public place and a workplace, to establish uniformity in tobacco control policies in Irish • Expected deliverables
the control of tobacco within the hospital is now of criti- 1. European endorsement for evidence based recom- cal importance. In 1997, the issue of tobacco in the hos- • While the long-term goal is to achieve a totally smoke- mendations on the treatment of tobacco dependence pital was identified as a problem area by many Irish HPH free environment in the hospital setting, the minimum for health care systems in Europe. member hospitals. A national survey of hospitals (1998) standards policy seeks to support the adoption of a 2. Preparation of re-submission for NRT to be placed found that majority of respondents 69 (95 %) reported committed, realistic and incremental approach. having a smoke-free policy however, the survey also • To be successful against tobacco requires that hospi- 3. Expansion of HECOS model to include other coun- demonstrated that a lack of clarity existed around the tals develop a framework that is complementary to exis- tries at the European and global level implementation of these policies. These findings suppor- 4. Workshops for senior national policy makers on ted previous and subsequent surveys conducted by treatment systems, including effectiveness and cost regional health authorities and individual hospitals. On May 30th, eve of “World No Tobacco Day”, the Minister for Health and Children, Mr. Michéal Martin TD, 5. Development, implementation and monitoring of The survey used a convenient sample of 93 hospitals launched the policy document and endorsed the partici- treatment programmes in target countries and achieved a 78 % (73) response rate. The survey pation of Irish hospitals both in the WHO/European HPH 6. Development and implementation of WHO training results highlighted a number of difficulties: Network and the EU/European Smoke-free Hospital programme, based on skills for change at postgra- Network. At the launch, the Minister described hospitals duate level for trainers of primary health care provi- • Inadequate staff knowledge of the policy; as key medical and knowledge reference centres that ders (physicians, nurses, pharmacists and dentists) in • Lack of staff ownership and clarity on their responsibi- can be decisive places not only for patients but also for families and the public at large. He considered that the 7. Development of arguments for reimbursement for • Unacceptable standards in designated smoking areas; Minimum Standard Smoke-Free Policy would positively treatment of tobacco dependence and advocacy at • Poor or non-existing monitoring procedures.
assist the smokers` decision-making process by creating an environment in which non-smoking is the norm. In this 8. Public health review of the use of treatment pro- Subsequently, the Network advocated that these issues way, the hospital sector of the Health Service can active- ducts for temporary abstinence and reduction in the should be addressed in a realistic and progressive way ly support and contribute to the achievement of a recent- through process of consensus and collective action. It ly launched national strategy, Towards a Tobacco Free 9. Legal assessment of clinical liability of practitioners was strongly viewed that until healthcare professio- failing to provide treatment for tobacco dependence nals/employees were seen to be demonstrating goodhealth practices, their healthcare advice would lack cre- In his address, Dr. Vincent Maher (Network Chairman) Activity 5 - Communicating a health message to
declared that all hospitals have clear moral and legal smokers
obligations to play a lead role in the fight against The activity will focus on the delivery of a health The HPH Network’s Tobacco Initiative initiated in 1996 tobacco. A Consultant Cardiologist in a leading Dublin message to smokers. An expert meeting on best prac- seeks to establish the following elements through a Teaching Hospital, Dr. Maher considered that “as yet hospital healthcare professionals continue to ignore this The artists project has commenced with the goal to • A clear understanding and minimum standards for killer that stalks openly in our midst, corrupting our chil- commission art on the theme of smoking cessation. dren even before they reach their teens”. He called for all The goal is to seek corporations to purchase twenty • Agreement on practical guidelines for the implementa- hospitals to provide comprehensive education and ces- pieces of commissioned art and to prepare posters sation support services to help those who wish to stop derived from the artwork for widespread dissemina- • Development of a common review and monitoring pro- smoking and further stated that if successful, it would tion throughout health care facilities and pharmacies save thousands of lives and millions of pounds, as well • The participation of Irish hospitals in the European as being in keeping with the modern concept of hospi- tals as health promoting centres rather than existing On March 8th, a national consensus workshop was orga- nised with the specific aim of addressing the need to develop a minimum standard smoke-free policy for Irish Ann O’Riordan
European Smoke-free
Hospital Code
European Smoke-free
Appoint an action group. Propose a strategy and an
implementation plan and coordonate activities.

Hospital Code
Grunden Sie einen Arbeitskreis für Tabakprävention.
Setzen Sie eine strategie fest für ein rauchfreies

As Tables of the Law given to Moses for application
Krankenhaus und Koordinieren Sie die notwendigen
of the Ten Commandments, the European Smoke-free
Hospital code is endowed with 10 points.
Mettre en place un comité de prévention du tabagisme.
Application and implementation of the point 2
Définir une stratégie et coordonner les actions.
Crear un comite de prevencíon del tabaquismo. Definir
Point 2: Appoint an action group. Propose a strategy
la estrategia y coordinar las actuaciones.
and an implementation plan and coordinate activities.
Istituire un comitato di prevenzione del tabagismo,
definire una strategia e coordinarne le attività.

ost of the hospitals, members of the French “Smoke-free Hospitals”network have appointed an action group for smoking prevention. This Criar una comissão de prevenção de tabagismo, definir
M group in the form of a committee is part of the hospital structure and uma estratégia e coordenar as acções.
is recognized by the management and validated by other instituional committees.
Members of the committee are volunteers who have in common the desire to reachpractical and balanced decisions to the tobacco problem. Beyond good will, per- creativy. How can one bring all these skills together ? Probably by gathering all the servance is one of the qualities committee members also need. Indeed, a great good will available, the organized change of the people involved, by the exchan- number of committees, created a few years ago only exist on paper and have ge and dissemination of information and the use of participating networks. It’s not stopped all activities. The coordination of activities ask for negotiating skills and such a bad idea to reproduce somebody else’s good idea in your own structure. Smoke-free Hospitals : the Belgien Experience
Why a Smoke-free Hospital but
implementation nor does it envisage penalties for its have even siezed the opportunity to stop smoking.
more importantly how can we limit
non-respect. This very much depends locally on the This tremendous success has been rewarded with hospital management’s good or not so good will. In the “Smoke-free Hospital Prize” awared in 1996. This the problems linked to smoking
addition, it is necessary to raise awareness among hospital has shared the prize with two other conten- in clinics and hospitals ?
hospital users (patients, visitors and staff). The message ders, the University Hospital Erasme in Brussels and to convey to smokers is that the sole aim of restric- the University clinics of Mont-Godinne.
ting smoking is to protect their and other people’s health and surely not to pester them. Banning A Federation against Cancer, modeled on the
Recent initiatives and project
smoking also has other consequences and has on Assistance Public Hopitaux de Paris’s initiative occasion in some hospitals provided the impetus to “Hôpital sans Tabac” has been meeting since 1993 in develop cessation strategies and services such as the French-speaking part of Belgium. Today this ini- t would be far too long to detail all the activities tiative has been developed internationally with the I the network has supported since its creation.
creation of a European Network of Smoke-free Suffice to say that the focus in the last two years has The network’ aims
been on pregnancy with the launch of a campaign Hospitals are by their very nature a place for smoking entitled “born and growing up smoke-free” organized prevention. All hospitals users have a common goal n 1993, we created in the French speaking part of in collaboration with FARES (Fondation against in the sense that they all try to defeat disease in one Belgium the network “Smoke-free Hospitals” with Respiratory affections and for Health Education). This way or another wether they are admitted for treat- the view to encourage local initiatives and facilitate project is conducted by the “ONE” network (birth and ment, visiting a patient or working as a health profes- information exchange. The model “Smoke-free sional. It is also a place where people suffer from the Hospital” should be understood as an attempt to limit For 2000, we plan with the collaboration of the Health consequences of smoking and where harm caused smoking as far as possible without banning it com- Promoting Hospitals to conduct activities to raise by tobacco can be witnessed daily (over 18 000 pletely in these institutions. Indeed, the number of awareness among trade union representatives. In the deaths per year in Belgium). Hospitals also welcome smokers combined with sometimes a very strong absence of official penalties for non-respect of people whose health is fragile and for whom environ- dependence to tobacco renders a straightforward smoking policy in the workplace, it is necessary to mental tobacco smoke is a hazard. Hospitals are also ban totally illusory if not on occasion even dangerous enlist the support of trade unions to ensure the hos- places where inflammable substances are kept in (fire hazard) if smokers are pushed into a situation pital compliance with smoking restrictions.
great quantities (oxygen, medical products.) presen- where they have to hide to smoke. This does not ting high fire risks. All these reasons lead to the however preclude a vigorous management of the In addition to developing contacts with the trade conclusion that hospitals and clinics are not compa- problem, and sometimes it has proven surprisingly union managers, a special meeting will be organised tible with tobacco use. This is recognized in the easy. For example, in the St Luc à Bouge clinic in in the automn for trade unions representatives in hos- Belgium Law dated 15th May 1990 which bans Namur, only one smoking room has been designated pitals. This meeting will provide an opportunity to smoking in places where patients and older people a smoking room. The only provision for staff , patients present examples of smoke-free policy in hospitals reside or are treated. The legal text also calls for and visitors alike, the rest of the building being strictly and to explain the reasons behind the need to repli- clearly marked areas for smokers to be located in smoke-free. A video produced in collaboration with cate the experience in other establishments. Health, such a place as to reduce as much as possible non- doctors based in hospitals, explaining the reason safety and well-being in the workplace will be the smokers exposure to environmental smoke.
behind such a restrictive policy is broadcasted at regular intervals in various parts of the establishment.
Is legislation sufficient ?
The results are clear. The smoking restrictions are not Dr D. Vander Steichel
only respected but in addition the great majority of Fédération Belge contre le Cancer patients and staff members (smokers and non- nfortunately it isn’t, especially because the law Chée de Louvain 479 - 1030 Bruxelles smokers) say they are happy with the policy, some U does not specify clearly who is in charge of its
Tél : 32 / 2 / 736 99 99 - Fax : 32 / 2 / 734 92 50. EUROPEAN SMOKE-FREE HOSPITAL NETWORK • 3RD ISSUE • JUNE 2000
Which Strategies for a
XXI century without tobacco
This was the theme of the European conference held on 3rd February 2000 traditionally in the Palis des
Congrès by the AP-HP hospitals in Paris. The event gathered over 400 experts, lawyers, hospital-
based medical personnel and other health professionals involved in tobacco control.

2000: a turning point
workplace and general practitioners, phar- in tobacco control ?
macists, but consumers are also responsible and have an important and strategic rôle to develop world strategies through its Geneva Indeed, in the last 10 years considerable pro- gress has been made at the European level in (TFI) presented by Derek Yach and Douglas The conclusions directed us towards conti- terms of legislation but also in the member nuing the debate and defining priorities to states in tackling tobacco addiction. A better better target our efforts. Rendez-vous in February 2001 for the next conference when therapy use has contributed to improve the become a priority. This approach in the deve- we will look in greater depth on the place rôle quality and quantity of cessation rates and lopment of our efforts was recommended by and the mission of hospitals in the struggle services. This topic was superbly treated by Humphrey, Attorney General for Washington Presentations texts are available on internet : industrialised and developing countries is www-tabac-net.ap-hop-paris.fr
The question is what strategies are needed to crucial to limit the expansion of the tobacco www.tabac-info.net
reverse this trend. National policy is not suf- epidemic, presentation by Thérèse Lethu, ficient to counteract the powerful tobacco Assistance Publique-Hopitaux de Paris, industry marketing strategy which knows no To tackle these challenges in the 21st , we all borders and is designed to recruit and hook have to play our part and health professio- nals in particular. This was the second part of the most vulnerable groups in society. This the conference . Smoking cessation specia- debate was presented by the French Deputy lists, occupational doctors and nurses in the End of Empiricism
Support and treatment to help smokers stop is one of a range of approaches to tobacco control. It complements other approaches (likepolicies to tax tobacco products, restrictions on their advertising, information and education) but addresses a specific group : those whowant to stop and need help. Smoking cessation in such adults brings population health gain more quickly than preventive approaches withyounger people.
Support and treatment to help smokers stop is not yet widely available. It is not integrated into the health care system anywhere in Europe,although some countries have made a start in this direction. Paradoxically, in contrast to the restricted availability of help for smokers instopping (including pharmaceutical products designed to aid tobacco withdrawal) the tobacco products whose use causes an enormousburden of death and disease are extremely widely available.
Core interventions should be integrated into health care systems. Interventions that have been shown to work by a large and consistentinternational body of evidence (a number of authoritative reviews: AHCPR Smoking Cessation Clinical Practiced guideline (summary), USA(1996) ; conclusions : Smoking Cessation Methods, National Institute of Public Health and Swedish Council on Technology, Assessment inHealth Care, Sweden (1998) ; Conclusions and recommendations of the Consensus conference, France (1999) ; Smoking CessationGuidelines and their cost effectiveness, England (1998)).
Broadly speaking the evidence supports the development of the three main types of intervention delivered by health professionals in thecourse of their routine work: brief interventions; more intensive support delivered by treatment specialists, often in what have been called« smokers-clinics » ; pharmacological adjuncts which approximately double cessation in minimal or more intensive settings. This last cate-gory currently includes nicotine replacement therapy and it is expected that it will soon in Europe include bupropion. The recommenda-tions for NRT will then also cover bupropion although there may be some differences as bupropion is likely to be prescription only.
Although the evidence base is stronger for some health professionals than others, the involvment of health professionals in offering help tosmokers should be based on factors such as access to smokers and level of training rather than professional discipline. Thus the recom-mendations for health professionals are relevant for all health professionals and not only those based in primary care. The essential fea-tures of individual smoking cessation advice have been described as the four As : Ask ( about smoking at every opportunity) ; Advise (allsmokers to stop) ; Assist (the smoker to stop) ; Arrange (follow-up).
Martin Raw - Guy’s King’s and St Thomas’ School of medecine; London

Source: http://ensh.free.fr/uk/gb_003.pdf


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