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BACKGROUND: The illicit tobacco trade results in huge losses of revenue to governments, estimated at $US40-50 billion in 2006, and in increased consumption and thus health problems because it makes tobacco available more cheaply. On 20 October 2008 the second meeting of the International Negotiating Body (INB2) on the illicit trade protocol of WHO's Framework Convention on Tobacco Control (FCTC) will discuss measures to tackle the illicit trade in tobacco products. METHODS: This paper presents the experience over the last decade of three countries, Italy, Spain and the United Kingdom, which shows that tobacco smuggling can be successfully tackled. CONCLUSION: The evidence strongly suggests that the key to controlling smuggling is controlling the supply chain, and that the supply chain is controlled to a great extent by the tobacco industry.

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OBJECTIVES: To quantify the implementation of tobacco control policies at country level using a new Tobacco Control Scale and to report initial results using the scale. METHOD: A questionnaire sent to correspondents in 30 European countries, using a scoring system designed with the help of a panel of international tobacco control experts. RESULTS: The 30 countries are ranked by their total score on the scale out of a maximum possible score of 100. Only four countries (Ireland, United Kingdom, Norway, Iceland) scored 70 or more, with an eight point gap (most differences in scores are small) to the fifth country, Malta, on 62. Only 13 countries scored above 50, 11 of them from the European Union (EU), and the second largest points gap occurs between Denmark on 45 and Portugal on 39, splitting the table into three groups: 70 and above, 45 to 62, 39 and below. Ireland had the highest overall score, 74 out of 100, and Luxembourg was bottom with 26 points. However even Ireland, much praised for their ban on smoking in public places, did not increase tobacco taxes in 2005, for the first time since 1995. CONCLUSIONS: Although the Tobacco Control Scale has limitations, this is the first time such a scale has been developed and applied to so many countries. We hope it will be useful in encouraging countries to strengthen currently weak areas of their tobacco control policy.

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More than 30% of all surgical activity for children in England and Wales is accounted for by routine ENT operations. There is known to be a high incidence of postoperative pain, nausea and vomiting following paediatric tonsillectomy with or without adenoidectomy. This prospective study examined the incidence of these complications in 100 children admitted for routine, elective day-case tonsillectomy, with or without adenoidectomy. The children were anaesthetised in accordance with our standard paediatric day-case protocol. The incidence of vomiting on the day of surgery was significantly less in the group anaesthetised in accordance with the protocol, compared to those in previously published studies. Postoperative pain was well controlled, with 88% of the children having minimal pain on the day of surgery, and reporting a pain score of 0-2. Modifying the anaesthetic care to a protocol designed to reduce postoperative pain, nausea and vomiting achieved measurable improvements in the recovery of this group following surgery. It has enabled us to evolve from a 100% inpatient stay for these operations to 98% day-case discharge rate, with minimal post anaesthetic or surgical morbidity. We describe the protocol and discuss the implications of implementing such a protocol for children undergoing these common operations.

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OBJECTIVES: Increasing the rate of smoking cessation remains a major public health goal. To help achieve this in the UK, National Health Service (NHS) smoking cessation services have been established to provide treatment for smokers wanting help with stopping. Referrals from general practitioners (GPs) are crucial to the success of these clinics. This study aimed to assess English GPs' self-reported interactions with, and attitudes towards, their local smoking cessation services. STUDY DESIGN: Postal survey assessing the attitudes of GPs in England towards, and formal interactions with, NHS smoking cessation services. METHODS: A questionnaire was posted to a random sample of 544 GPs in England (response rate 63%). GPs' self-reported interactions with smoking cessation services and their attitudes towards these clinics were assessed. GPs were also asked what factors determined whether they prescribed nicotine-replacement therapy (NRT) and Buproprion (Zyban), and what was the extent and nature of their smoking cessation interventions with their patients. RESULTS: Most GPs (94%) reported that they were aware of the specialist smoking cessation service in their area. Seventy percent of GPs supported the continuation of current funding for specialist smoking cessation services. Seventy percent reported that they referred patients to these services, and 55% had staff within their practices trained as community smoking cessation advisors. Most GPs (79%) reported 'clinical need' as a determinant of whether they prescribed NRT/Zyban, and a few GPs cited 'budgetary constraints' as a factor (15%). Ninety-eight percent of GPs reported that they record smoking status when new patients join their practice, and they advise smokers to stop 'at least every now and then'. CONCLUSIONS: GPs support the existence and continuation of specialist smoking cessation services, and most reported that they refer patients to them. Virtually every GP reported that they record smoking status when new patients join their practice, and they advise smokers to stop 'at least every now and then'.

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Smokeless tobacco is used in the UK predominantly by members of the Indian, Pakistani and especially Bangladeshi communities. The most commonly used form is tobacco mixed with lime and additional psychoactive compounds, most notably areca nut. The resulting "quid" is chewed or held in the mouth. Studies from Asia indicate that use of this kind of product is linked with an increased risk of oral cancers and possibly low birth-weight infants. There is little high quality research evaluating interventions to promote cessation of smokeless tobacco use, especially of the forms used in the UK. However, what evidence there is suggests that advice to stop coupled with behavioural support and counselling may increase long-term abstinence rates by some 5-10%. It seems appropriate therefore to recommend that dentists, GPs and other relevant health professionals should routinely assess and record smokeless tobacco use in patients belonging to relatively high prevalence groups, that they ensure that smokeless tobacco users know the potential health risks (as well as the health risks of smoking) and that they advise them to stop and keep a record of the outcome. Dental professionals should also examine the oral cavity of smokeless tobacco users for lesions when the opportunity arises. Patients expressing an interest in stopping should be referred to specialist smoking cessation services for behavioural support and specialists in areas of high smokeless tobacco use will need to ensure that they are sufficiently knowledgeable and their services sufficiently accessible to these users. There is insufficient evidence to recommend the use of nicotine replacement therapy or bupropion to aid smokeless tobacco cessation. Research is needed in the UK to quantify the personal and population health risks from smokeless tobacco, the benefits of stopping, the effectiveness of interventions aimed at promoting cessation and patterns of use, knowledge and attitudes of users.

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The tobacco industry has argued that tobacco smuggling is caused by market forces, i.e., by the price differences between countries, which create an incentive to smuggle cigarettes from 'cheaper' to 'more expensive' countries, and so urged governments to solve the problem by reducing taxes to remove this differential, which will also, they say, restore revenue. Although such market forces have some effect, smuggling is in fact more prevalent in 'cheaper' countries, and reducing tax is not the solution. Where taxes have been reduced tobacco consumption has risen and revenue has fallen, with disastrous consequences for public health. The key to understanding cigarette smuggling is understanding the role of the tobacco industry. At the heart of cigarette smuggling is large scale fraud: container loads of cigarettes are exported, legally and duty unpaid, to countries where they have no market, and where they disappear into the contraband market. They are often smuggled back into the country of origin, where they are sold at a third to half price. It is therefore profitable because duty has been illegally evaded. The key to controlling cigarette smuggling is not lowering taxes, it is controlling the tobacco manufacturing industry and its exporting practices.

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The World Health Organization estimates that tobacco will become the largest single health problem by 2020, causing an estimated 8.4 million deaths annually. But the smoking burden will not be distributed evenly across the globe; deaths in developed nations are set to rise 50% to 2.4 million while those in Asia will soar fourfold to an estimated 4.2 million in 2020. In the face of such discrepancy, Martin Raw, Honorary Lecturer in evidence-based treatment at Guys, Kings and St Thomas' School of Medicine, London, explains why attention can not be focused solely on Asia and why efforts are still needed to stop smoking in Europe.

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This paper updates the evidence base and key recommendations of the Health Education Authority (HEA) smoking cessation guidelines for health professionals published in Thorax in 1998. The strategy for updating the evidence base makes use of updated Cochrane reviews supplemented by individual studies where appropriate. This update contains additional detail concerning the effectiveness of interventions as well as comments on issues relating to implementation. The recommendations include clarification of some important issues addressed only in general terms in the original guidelines. The conclusion that smoking cessation interventions delivered through the National Health Service are an extremely cost effective way of preserving life and reducing ill health remains unchanged. The strategy recommended by the guidelines involves: (1) GPs opportunistically advising smokers to stop during routine consultations, giving advice on and/or prescribing effective medications to help them and referring them to specialist cessation services; (2) specialist smokers' services providing behavioural support (in groups or individually) for smokers who want help with stopping and using effective medications wherever possible; (3) specialist cessation counsellors providing behavioural support for hospital patients and pregnant smokers who want help with stopping; (4) all health professionals involved in smoking cessation encouraging and assisting smokers in use of nicotine replacement therapies (NRT) or bupropion where appropriate. The key points of clarification of the previous guidelines include: (1) primary health care teams and hospitals should create and maintain readily accessible records on the current smoking status of patients; (2) GPs should aim to advise smokers to stop, and record having done so, at least once a year; (3) inpatient, outpatient, and pregnant smokers should be advised to stop as early as possible and the advice recorded in the notes in a readily accessible form; (4) there is currently little scientific basis for matching individual smokers to particular forms of NRT; (5) NHS specialist smokers' clinics should be the first point of referral for smokers wanting help beyond what can be provided through brief advice from the GP; (6) help from trained health care professionals specialising in smoking cessation such as practice nurses should be available for smokers who do not have access to specialist clinics; (7) the provision of specialist NHS smokers' clinics should be commensurate with demand; this is currently one or two full time clinics or their equivalent per average sized health authority, but demand may rise as publicity surrounding the services increases.

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BACKGROUND: Employers have responded to new regulations on the effects of passive smoking by introducing a range of workplace policies. Few policies include provision of smoking cessation intervention. OBJECTIVE: To estimate the cost to employers of smoking in the workplace in Scotland to illustrate the potential gains from smoking cessation provision. Costs vary with type of smoking policy in place; therefore, to estimate these costs results from a survey were combined with evidence drawn from a literature review. STUDY DESIGN: A telephone survey of 200 Scottish workplaces, based on a stratified random sample of workplaces with 50 or more employees, was conducted in 1996. Additional evidence was compiled from a review of the literature of smoking related costs and specific smoking related effects. RESULTS: 167 completed responses were received, of which 156 employers (93%) operated a smoking policy, 57 (34%) operated smoke free buildings, and 89 (53%) restricted smoking to a "smoke room". The research literature shows absenteeism to be higher among smokers when compared to non-smokers. The estimated cost of smoking related absence in Scotland is pound40 million per annum. Total productivity losses are estimated at approximately pound450 million per annum. In addition, the resource cost in terms of losses from fires caused by smoking materials is estimated at approximately pound4 million per annum. In addition, there are costs from smoking related deaths and smoking related damage to premises. CONCLUSION: This study shows how smoking cessation interventions in the workplace can yield positive cost savings for employers, resulting in gains in productivity and workplace attendance which may outweigh the cost of any smoking cessation programme.

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Cigarette smuggling, now on the increase, is so widespread and well organised that it poses a serious threat to public health. This threat comes from two principal directions. First, smuggling makes cigarettes available cheaply, thereby increasing consumption. A third of annual global exports go to the contraband market, representing an enormous impact on consumption, and thus causing an increase in the burden of disease, especially in poorer countries. It is also costing government treasuries thousands of millions of dollars in lost tax revenue. Second, the tobacco industry uses smuggling politically, lobbying governments to lower tax, arguing that smuggling is caused by price differences. This paper shows that the claimed correlation between high prices and high levels of smuggling does not exist in western Europe. In fact, countries such as Norway and Sweden, with expensive cigarettes, do not have a large smuggling problem, whereas countries in the south of Europe do. Cigarette smuggling is not caused principally by "market forces". It is mainly caused by fraud, by the illegal evasion of import duty. The cigarettes involved are not the cheap brands from southern European countries, for which there is no international market. It is the well-known international brands such as Marlboro and Winston. We propose much tighter regulation of cigarette trade, including an international transport convention, and a total ban on transit trade-sale by the manufacturers to dealers, who sell on to smugglers.

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The European Union spends about 1000m ecu (800m pounds, $1240m) a year subsidizing tobacco production but only about 1.55m ecu (1.2m pounds, $1.85m) on smoking prevention. The subsidies, part of the common agricultural policy, were originally intended to encourage farmers to grow commercially valued varieties of tobacco and thus reduce imports. But they also aimed to guarantee farmers' income, a goal in direct conflict with the first. The policy has failed to adapt production to demand or reduce imports, since most tobacco grown in the union has little commercial value. Reforms introduced in 1992 have had limited impact on expenditure, and data produced as a result of the reforms show that it would be much cheaper to give farmers direct income support than to subsidize them growing tobacco. Tobacco subsidies should be abolished and more should be spent on smoking prevention.

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