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1. Lambers DS, Clark KE. The maternal and fetal physiological effects of nicotine. Semin Perinatol 1996; 20: 115-126.
2. Hellstrom-Lindahl E, Nordberg A. Smoking during pregnancy: a way to transfer addiction to the next generation? Respiration2002; 69: 289-293.
3. Pittilo MR. Cigarette smoking, endothelial injury and cardiovascular disease. Int J Exp Pathol 2000; 81: 219-230.
4. Puranik R, Celermajer DS. Smoking and endothelial function. Prog Cardiovasc Dis 2003; 45:
443-458.
5. Lain KY, Wilson JW, Crombleholme WR, Ness RB, Roberts JM, Smoking during pregnancy is associated with alterations in markers of endothelial function. Am J Obstet Gynecol 2003; 189:
1196-1201.
6. Salafia C, Shiverick K. Cigarette smoking and pregnancy II: Vascular effects. Placenta1999; 20:
273-279.
7. Ashmead GG. Smoking and pregnancy. J Matern Fetal Neonatal Med2003; 14: 297-304.
8. Lackmann GH, Salzberger U, Tollner U, Chen M, Camella SG, Hecht SS. Metabolites of a tobacco specific carcinogen in the urine of newborns. J Natl Cancer Inst1999; 91: 459-465.
9. Castles A, Adams EA, Melvin CL, Kelsch C, Boulton ML. Effects of smoking in pregnancy.
Am J Prev Med1999; 16: 208-215.
10. Wyzynski DF, Duffy DL, Beaty TH. Maternal cigarette smoking and oral clefts: a meta analysis. Cleft Palate Craniofac J1997; 34: 206-211.
11. Sasco AJ, Vainio H. From in utero exposure to parental smoking to childhood cancer: a possible link and need for action. Hum Exp Toxicol 1999; 18: 192-201.
12. Anderson H, Cook DG. Passive smoking and sudden infant death syndrome: review of the epidemiological evidence. Thorax1997; 52: 1003-1009.
13. Odendaal HJ, Van Schie DL, De Jeu RM. Adverse effects of cigarette smoking on preterm labour and abruptio placentae.Int J Gynaecol Obstet2001; 74: 287-288.
14. Surgeon General’s Report on Women and Smoking: Marketing Cigarettes to Women.
www.cdc.gov/tobacco/sgr_forwomen/index.htm(2001).
15. Steyn K, Yach D, Stander I, Fourie JM. Smoking in urban pregnant women in South Africa. S Afr Med J 1997; 87: 460-463.
The theme for World No Tobacco Day on 31 May 2005 is
‘Health Professionals against Tobacco’. Doctors in South Africa are missing clinical opportunities to help patients who use tobacco, and recognising and taking advantage of these opportunities will require changes in the education of medical students.
In 1979, M A H Russell and his colleagues in London published research that created a sensation in smoking cessation circles.1The study demonstrated that following simple but firm advice to stop smoking from their general practitioner, about 5% of smokers would quit. While the impact of an individual GP may be small, collective action by the profession would yield impressive change. Russell et al.
calculated that if all GPs in Britain gave anti-smoking advice to their patients on at least one occasion, half a million patients would stop smoking as a direct result – a target unlikely to be matched if the 50 specialised smoking cessation clinics then operating in the UK were increased to 10 000.
In South Africa, if our 200 000 registered health professionals each helped one patient to stop smoking per month this would produce 2.4 million ex-smokers a year and dramatically reduce the numbers of smokers in this country. However, harnessing the power of doctors to turn smokers into ex-smokers remains an elusive goal in public health.
On 31 May, World No Tobacco Day, the World Health Organization once again focuses on the role of health
professionals in tobacco control. Health workers, and especially doctors, are in a unique position to help smokers. Patients expect to get information, help and guidance from their doctor on health matters. It is the doctor who is most trusted and whose advice has the most impact upon people’s health.
Yet anecdotal evidence suggests that the average GP seldom raises the issue of smoking during a consultation. GPs frequently do not know which of their patients smoke, and as often fail to advise them to stop even when this should be part of the treatment. There are several reasons why doctors have failed to act. Perhaps the most important is that many doctors, even those deeply concerned about the harm caused by tobacco, feel powerless to influence their patient’s behaviour.
Many believe they lack expertise, and that they have little to offer their patients who need help.
This pessimism is misplaced. A doctor can both motivate and help people stop smoking. At the very least a doctor can refer the patient who says ‘I’ve tried everything and nothing works’
to the Tobacco or Health Information Line (on (011) 720-3145) for counselling.
The reluctance of doctors to act points to a deeper problem.
There is insufficient education for health professionals in this area. In fact, the whole area of medical training is under challenge. Doctors have been criticised for ‘practising 19th- century medicine in the 21st century’. It is argued that the training of medical students has to change so that over time doctors will move from the reactive care of individual patients with acute illness to the proactive, planned and preventive care of populations.2 The WHO has suggested that training has to be restructured to include a new set of competencies to help health workers manage today’s most prevalent health problems.2
Among the new competencies required is helping people deal with addictions, eating disorders and other lifestyle problems. Currently no school of public health in South Africa has a chair on addictions. The University of the Witwatersrand has a teaching block on tobacco control, but in the others
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instruction about tobacco is probably still based on anatomical site and is episodic rather than systematic.
Schools of public health should therefore examine their curricula with a view to initiating courses that would enable their graduates to better diagnose, manage and treat dependence. A starting point for change is to develop guidelines for an ‘ideal’ tobacco curriculum which could provide a template to enhance tobacco education of medical students throughout the country. This is a matter of some urgency.
Beyond the clinic, in countries like Australia, the UK and Sweden doctors have served as excellent role models for smoking cessation. Smoking rates among doctors are typically below 6% and considerably lower than in the general
population. In South Africa little is known about the prevalence of tobacco use among health workers, their attitudes to smoking cessation or the teaching on tobacco in our universities. Research on these matters is now a prerequisite to action.
Finally, doctors have an important role as advocates for effective tobacco control policies. WHO recommends that health workers use their prestige and credibility in their
communities to speak out on the dangers of smoking at every appropriate forum. Further, ‘professional health organisations represent a powerful lobby to press for adoption of tobacco control legislation’. An early opportunity to act will be presented when parliament considers strengthening the tobacco legislation later this year.
Yussuf Saloojee
National Council Against Smoking PO Box 1242
Houghton 2041
Krisela Steyn
Chronic Diseases of Lifestyle Unit Medical Research Council Tygerberg, W Cape
Corresponding author:Y Saloojee ([email protected])
1. Russell MAH, Wilson C, Taylor C, Baker CD. Effect of general practitioners' advice against smoking. BMJ1979; 2:231-235.
2. Pruit SD, Epping-Jordan JAE. Preparing the 21st century global healthcare workforce. BMJ 2005; 330:637-639.
086 0100 678 www.medihelp.co.za
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