Tobacco smoke incursion into private residences in Israel: a cross-sectional study examining public perceptions of private rights and support for governmental policies.

BACKGROUND: Tobacco smoke incursion (TSI) into private residences is a widespread problem in many countries. We sought to assess the prevalence of self-reported TSI and public attitudes about TSI in Israel, a country with a relatively high smoking prevalence and high population density. METHODS: We conducted a random digit dial survey among residents in Israel (N = 285) in 2017, which examined the frequency, source, correlates of, and attitudes towards TSI and potential regulatory options. The cooperation rate was 63.9%. RESULTS: Among respondents, 44.7% reported ever experiencing home TSI, with higher exposure among residents of multi-unit housing (MUH) (MUH versus private homes: aOR (Adjusted Odds Ratio): 3.60, CI (Confidence Interval): [1.96, 6.58], p < .001). Most respondents (69.8%), including nearly half of smokers, prioritized the right of individuals to breath smoke-free air in their apartments over the right of smokers to smoke in their apartments. Women and non-smokers were more likely to support the right to breathe smoke-free air (Women versus men: aOR: 2.77 CI: [1.48, 5.16], p = .001; Nonsmokers versus smokers: aOR: 3.21 CI [1.59, 6.48], p = .001). However, only about a quarter (24.8%) of respondents who ever experienced TSI raised the issue with the neighbor who smoked, the neighbor's landlord, or the building committee. The vast majority (85.2%) of all respondents, including three-quarters of smokers, supported smoke-free legislation for multi-unit housing (MUH), with those ever-exposed to TSI and non-smokers more likely to support legislation (ever-exposed versus never-exposed aOR = 2.99, CI [1.28, 6.97], p = 0.011; nonsmokers versus smokers aOR = 3.00, CI [1.28, 7.01], p = 0.011). CONCLUSIONS: Among study participants, tobacco smoke incursion was a common, yet unwelcome experience. Most respondents believed that the right to breathe smoke-free air in one's apartment superseded that of neighbors to smoke anywhere in their home, and most supported legislation to prevent TSI. Though further study is needed to understand better TSI and effective methods for its prevention, our findings suggest that policy interventions, including legal action at the level of the Supreme Court and/or the Knesset, are needed. Regulation, policy initiatives and campaigns to denormalize smoking in proximity to other people and private residences globally could reduce the scope of this widespread problem, protect individuals from home TSI, and improve population health.

The association between risk perceptions, anxiety, and self-reported changes in tobacco and nicotine product use due to COVID-19 in May-June 2020 in Israel.

BACKGROUND: Early in the COVID-19 pandemic, reports about a possible protective effect of nicotine on COVID-19 conflicted with messaging by public health organizations about increased risks of COVID-19 due to smoking. The ambiguous information the public received, combined with COVID-19-induced anxiety, may have led to changes in tobacco or other nicotine product use. This study examined changes in use of combustible cigarettes (CCs), nargila (hookah/waterpipe), e-cigarettes, and IQOS and home-smoking behaviors. We also assessed COVID-19 related anxiety and perceptions regarding changes in risk of COVID-19 severity due to smoking. METHODS: We used cross-sectional data from a population telephone survey that was conducted in Israel in the early phase of the COVID-19 pandemic (May-June 2020) and included 420 adult (age 18+) individuals who reported having ever used CCs (n = 391), nargila (n = 193), and/or electronic cigarettes (e-cigarettes)/heated tobacco products (e.g., IQOS) (n = 52). Respondents were asked about the effect that COVID-19 had on their nicotine product use (quit/reduced use, no change, increased use). We assessed changes in product use, risk perceptions, and anxiety using adjusted multinomial logistic regression analyses. RESULTS: Most respondents did not change their frequency of product use (CCs: 81.0%, nargila: 88.2%, e-cigarettes/IQOS: 96.8%). A small percentage either decreased use (CCs: 7.2%, nargila: 3.2%, e-cigarettes/IQOS:2.4%) or increased use (CCs:11.8%, nargila:8.6%, e-cigarettes/IQOS:+ 0.9%). 55.6% of respondents used a product in the home prior to COVID-19; but during the first lockdown COVID-19 period, a greater percentage increased (12.6%) than decreased (4.0%) their home use. Higher levels of anxiety due to COVID-19 were associated with increased home smoking (aOR = 1.59, 95% CI:1.04-2.42, p = 0.02). Many respondents believed that increased severity of COVID-19 illness was associated with CCs (62.0%) and e-cigarettes/vaping (45.3%), with uncertainty about the association being lower for CCs (20.5%) than for vaping (41.3%). CONCLUSIONS: While many respondents believed that nicotine product use (particularly CCs and e-cigarettes) was associated with increased risk of COVID-19 disease severity, the majority of users did not change their tobacco/nicotine use. The confusion about the relationship between tobacco use and COVID-19 calls for clear evidence-based messaging from governments. The association between home smoking and increased COVID-19-related stress suggests the need for campaigns and resources to prevent smoking in the home, particularly during times of stress.

Tobacco Smoke Exposure According to Location of Home Smoking in Israel: Findings from the Project Zero Exposure Study.

Young children are particularly vulnerable to harms from tobacco smoke exposure (TSE). This study aimed to compare TSE: (1) between children who live in smoking families and those who do not; and (2) among children who live in smoking households with varying smoking locations. The data came from two studies that were conducted concurrently in Israel (2016-2018). Study 1: a randomized controlled trial of smoking families (n = 159); Study 2: a cohort study of TSE among children in non-smoking families (n = 20). Hair samples were collected from one child in each household. Baseline hair nicotine data were analyzed for 141 children in Study 1 and 17 children in Study 2. Using a logistic regression analysis (exposed vs. not exposed as per laboratory determination) and a linear regression (log hair nicotine), we compared TSE between: (1) children in Study 1 vs. Study 2; (2) children in families with different smoking locations in Study 1: balcony; garden, yard, or other place outside of the home; or inside the home (designated smoking areas within the home (DSAs) or anywhere). A higher proportion of children living in smoking households were measurably exposed to tobacco smoke (68.8%) compared to children living in non-smoking households (35.3%, p = 0.006). Among children from smoking families, 75.0% of those whose parents smoked in the house were exposed, while 61.8% of children whose parents restricted smoking to the porch (n = 55) were exposed, and 71.4% of those whose parents smoked outside the home (including gardens and yards) (n = 42) were exposed. In univariable and multivariable models, smoking location was not significantly associated with exposure. The majority of children in smoking families were measurably exposed to TSE, even if smoking was restricted to designated areas in the home, balconies, orgarden/yard/other outdoor areas. Reducing population smoking rates, particularly among parents, restricting smoking to at least 10 meters from homes and children, and denormalizing smoking around others are recommended to reduce population-level child TSE and tobacco-attributable disease and death.

Association between objective measures and parent-reported measures of child tobacco smoke exposure: A secondary data analysis of four trials.

INTRODUCTION: Tobacco smoke exposure (TSE) harms children and adults. Studies of childhood TSE exposure often relies on parental reports, but may benefit from objective measures. The objective of our study was to study the relationship between reported and objective measures of TSE. METHODS: We analyzed data from four intervention trials, conducted in clinical or community settings, to identify objective measures most closely associated with parent-reported measures and the optimal set of parent-reported measures for predicting objective measures. We also assessed whether there was a learning curve in reported exposure over time, and the importance of replicate biomarker measures. RESULTS: Correlations between objective and parent-reported measures of child TSE were modest at best, ranging from zero to 0.41. Serum cotinine and urinary cotinine were most strongly associated with parental reports. Parental questions most closely related to biomarkers were number of cigarettes and home smoking rules; together these formed the best set of predictive questions. No trial included all objective measures and all questions, precluding definitive statements about relative advantages. Within-subject repeatability of biomarker measures varied across studies, suggesting that direct pilot data are needed to assess the benefit of replicate measurements. CONCLUSIONS: Improvements in objective and parent-reported child exposure measurements are needed to accurately monitor child TSE, evaluate efforts to reduce such exposure, and better protect child health.

Beyond "Safe and Effective": The urgent need for high-impact smoking cessation medications.

Smoking cessation medications (SCMs) are an evidence-based cornerstone of comprehensive tobacco control programs globally. However, the impact of SCMs on population smoking prevalence is controversial, with inconsistencies between randomized controlled trials (RCTs) and population-based observational studies. We estimated SCM impact on permanent cessation and population smoking prevalence by extrapolating efficacy estimates from meta-analyses of RCTs, using the standard population impact formula: efficacy*reach. We calculated the potential SCM impact under a range of assumptions for permanent cessation (20%,14%), behavioral support (yes/no), reach (40%-2%), and underlying smoking prevalence. Assuming behavioral support for all, depending on reach, 8%-0.3% of smokers are expected to quit permanently. Without behavioral support, permanent cessation is estimated to be 6.4%-0.2%. Assuming an underlying population smoking prevalence of 14%, (current U.S. prevalence), the maximum impact on population smoking prevalence is 1.12%. Impact on prevalence increases with increasing underlying country-specific levels of prevalence. With current U.S. levels of reach, behavioral support and smoking prevalence, we estimate that, based on a single course of treatment, 2.3% of smokers would quit permanently, contributing to a 0.3% decrease in population level smoking prevalence. Even under ideal conditions, the potential of current first-line SCMs to increase cessation in a substantial proportion of smokers, and reduce population smoking prevalence, is limited. In order to avert the predicted billion tobacco-caused deaths in this century, "safe and effective" medications are not sufficient: SCMs with high population impact are urgently needed. Policies to ensure the availability and accessibility of highly efficacious SCMs, with behavioral support, are crucial.

Parental Perceptions of Children's Exposure to Tobacco Smoke and Parental Smoking Behaviour.

Around 40% of children are exposed to tobacco smoke, increasing their risk of poor health. Previous research has demonstrated misunderstanding among smoking parents regarding children's exposure. The parental perceptions of exposure (PPE) measure uses visual and textual vignettes to assess awareness of exposure to smoke. The study aimed to determine whether PPE is related to biochemical and reported measures of exposure in children with smoking parents. Families with at least one smoking parent and a child ≤ age 8 were recruited. In total, 82 parents completed the PPE questionnaire, which was assessed on a scale of 1-7 with higher scores denoting a broader perception of exposure. Parents provided a sample of their child's hair and a self-report of parental smoking habits. Parents who reported smoking away from home had higher PPE ratings than parents who smoke in and around the home (p = 0.026), constituting a medium effect size. PPE corresponded with home smoking frequency, with rare or no home exposure associated with higher PPE scores compared to daily or weekly exposure (p < 0.001). PPE was not significantly related to hair nicotine but was a significant explanatory factor for home smoking location. PPE was significantly associated with parental smoking behaviour, including location and frequency. High PPE was associated with lower exposure according to parental report. This implies that parental understanding of exposure affects protective behaviour and constitutes a potential target for intervention to help protect children.

Changing Exposure Perceptions: A Randomized Controlled Trial of an Intervention with Smoking Parents.

Children who live with smokers are at risk of poor health, and of becoming smokers themselves. Misperceptions of the nature of tobacco smoke exposure have been demonstrated among parents, resulting in continued smoking in their children's environment. This study aimed to change parents' perceptions of exposure by providing information on second- and third-hand exposure and personalised information on children's exposure [NIH registry (NCT02867241)]. One hundred and fifty-nine families with a child < 8 years and at least one smoking parent were randomized into intervention (69), control (70), and enhanced control (20) groups. Reported exposure, parental smoking details, and a child hair sample were obtained at the start of the study and 6-8 months later. Parental perceptions of exposure (PPE) were assessed via a questionnaire. The intervention consisted of motivational interviews, feedback of home air quality and child's hair nicotine level, and information brochures. PPE were significantly higher at the study end (94.6 ± 17.6) compared to study beginning (86.5 ± 19.3) in intervention and enhanced control groups (t(72) = -3.950; p < 0.001). PPE at study end were significantly higher in the intervention group compared to the regular control group (p = 0.020). There was no significant interaction between time and group. Parallel changes in parental smoking behaviour were found. Parental perceptions of exposure were increased significantly post intervention, indicating that they can be altered. By making parents more aware of exposure and the circumstances in which it occurs, we can help parents change their smoking behaviour and better protect their children.

Monitoring secondhand tobacco smoke remotely in real-time: A simple low-cost approach.

INTRODUCTION: Secondhand smoke (SHS) in the home is a serious cause of ill-health, especially for children. SHS indoors can be indirectly measured using particulate matter monitors, and interventions have been developed using feedback from these monitors to encourage smoke-free homes. These interventions often use data that are several days out of date, as the data must be downloaded manually from monitors. It would be advantageous to access this information remotely in real-time to provide faster feedback to intervention participants. METHODS: Using off-the-shelf computer components and the Dylos DC1700 air quality monitor, a portable internet-connected monitor was developed that can send data to a server remotely. Four of these monitors were tested in homes in Israel to test the reliability of the connection. Data were downloaded from the monitor's onboard memory and compared to the data sent to the server. RESULTS: Eight homes were monitored for 4 to 6 days, with a combined total count of 44 days. Less than 1% of data was lost, with no outage lasting longer than 1 hour 45 minutes. There was no significant difference in the mean concentrations measured in homes between mobile-transmitted data and data downloaded directly. CONCLUSIONS: This system appears to be a reliable way to monitor remotely home air quality for use in intervention studies, and could potentially have applications in other related research. Laboratories that own Dylos DC1700s may wish to consider converting them to such a system to obtain a cost-effective way of overcoming limitations in the Dylos design.

Health-related behaviours and perceptions among physicians: results from a cross-sectional study in Israel.

OBJECTIVES: Physicians' demanding work conditions may reduce the time and energy required for maintaining healthy lifestyles. This study examined health-related behaviours, perceived health status and emotional stress among physicians, and analysed the effects of personal and work characteristics on these endpoints. DESIGN: A cross-sectional study using a digital questionnaire. SETTING AND PARTICIPANTS: All 25 590 physicians who were members of the Israeli Medical Association in 2015 were invited to participate by email. Of 14 694 who opened the e-mail, 4832 (32.9%) responded. OUTCOME MEASURES: Survey topics included physical activity (PA), nutrition and eating habits, smoking, sleep, perceived health status and emotional stress, body mass index (BMI) and contact with a regular physician, as well as personal and work characteristics. Univariate and multivariate analyses were performed. RESULTS: Of the 4832 respondents, 21% reported poor or fair health status, 36% felt considerable emotional stress, 57% were overweight or obese (according to BMI≥25 kg/m2), 71% did not meet the recommended PA level, 79% did not meet a composite measure of healthy nutrition, 8% were current smokers, 25% slept 5 hours or less and 57% did not have a regular physician. Residents and hospital physicians reported significantly less healthy lifestyles, lower perceived health status and higher stress levels, compared with senior and community physicians. Multivariate analysis demonstrated that being female (OR=0.74, 95% CI=0.64 to 0.85), younger (0.69, 0.64 to 0.74), having poor nutrition (0.66, 0.55 to 0.78), not meeting PA targets (0.68, 0.57 to 0.82), inadequate sleep (0.54, 0.40 to 0.56) and perceived poor health status (0.48, 0.40 to 0.56) were significantly associated with high stress levels (p<0.001). CONCLUSIONS: The unfavourable health behaviours reported among Israeli physicians may have negative effects on their health and well-being. An intervention program to help physicians to adopt a healthier lifestyle is urgently needed.

Knowledge and risk perceptions of Israelis towards combustible cigarettes: the need for immediate remedial action.

BACKGROUND: Devastation from the tobacco epidemic continues, with strong government tobacco control policy absent in most countries. Knowledge of the full scope of tobacco harm in populations may form the basis for healthier behavior, de-normalization of smoking, and a consensus about necessary public policy. However, many populations may be poorly-informed about the risks, and this ignorance may undermine both effective policy-making and implementation of tobacco control policies. We present knowledge and risk perceptions about smoking tobacco smoke exposure in Israel. METHODS: A nationally-representative phone survey was conducted in Israel (n = 505; response rate = 61%). We assessed knowledge about active and passive smoking using four questions, three of which addressed knowledge about harm, and one of which addressed knowledge of tobacco-related harm relative to knowledge of harm due to traffic accidents. The three questions which addressed knowledge of harm were combined into a composite score. We also asked four risk perception questions concerning tobacco smoke exposure, which were measured on a 7-point Likert scale and then combined. Multivariable logistic regression and linear models were used to identify whether smoking status or socio-demographic variables were associated with knowledge of harm, comparative knowledge of harm, and risk perceptions. RESULTS: Just two in five respondents, and one in five respondents who were current smokers, accurately answered three simple questions about harms of smoking. Fewer than three in ten respondents, and fewer than one in five smokers, knew that smoking causes more damage than traffic accidents. Many (30.3%) were unaware that tobacco smoke exposure causes both lung cancer and heart disease, 27.7% did not know that smoking both shortens life and injures quality of life, and 31.1% did not know that smoking-attributable health problems will afflict all or most heavy smokers. Overall, risk perceptions regarding tobacco smoke exposure were high (mean = 24.5, SD:4.5, on a scale of 7-28, with 28 the indicating highest level). Smoking status was consistently associated with lower levels of knowledge, comparative knowledge, and risk perceptions, with current smokers having the lowest levels of knowledge and the lowest risk perceptions. CONCLUSIONS: Like many others, Israelis, and particularly Israeli smokers, do not fully grasp tobacco's true dangers. Effective communication of the full range of tobacco risks to the public, with a focus on communication with smokers, is an essential component of comprehensive tobacco control policy.

Diminishing benefit of smoking cessation medications during the first year: a meta-analysis of randomized controlled trials.

BACKGROUND AND AIMS: Although smoking cessation medications have shown effectiveness in increasing abstinence in randomized controlled trials (RCTs), it is unclear to what extent benefits persist over time. This paper assesses whether the benefits of smoking cessation medications decline over the first year. METHODS: We selected studies from three systematic reviews published by the Cochrane Collaboration. RCTs of first-line smoking cessation medications, with 6- and 12-month follow-up, were eligible for inclusion. Meta-analysis was used to synthesize information on sustained abstinence (SA) at 6 versus 12 months and 3 versus 6 months, using the risk difference (RD) ('net benefit') between intervention and control group quit rates, the relative risk (RR) and the odds ratio (OR). RESULTS: Sixty-one studies (27 647 participants) were included. Fewer than 40% of intervention group participants were sustained abstinent at 3 months (bupropion: 37.1%; nicotine replacement therapy (NRT): 34.8%; varenicline: 39.3%); approximately a quarter were sustained abstinent at 6 months (bupropion: 25.9%; NRT: 26.6%; varenicline: 25.4%), and approximately a fifth were sustained abstinent at 12 months (bupropion: 19.9%; NRT: 19.8%%; varenicline: 18.7%). There was only a small decline in RR (3 months: 1.95 [95% confidence interval (CI) = 1.74-2.18, P < 0.0001]; 6 months: 1.87 (95% CI = 1.67-2.08 P < 0.0001); 12 months: 1.75 (95% CI = 1.56-1.95, P < 0.0001) between intervention and control groups over time, but a substantial decline in net benefit [3 months: RD = 17.3% (14.5-20.1%); 6 months: RD = 11.8% (10.0-13.7%); 12 months: RD = 8.2% (6.8-9.6%)]. The decline in net benefit was statistically significant between 3 and 6 [RD = 4.95% (95% CI = 3.49-6.41%), P < 0.0001] and 6 and 12 months [RD = 3.00% (95% CI = 2.36%-3.64%), P < 0.0001)] for medications combined and individual medications. CONCLUSIONS: The proportion of smokers who use smoking cessation medications who benefit from doing so decreases during the course of the first year, but a net benefit still remains at 12 months.

Parental Perceptions and Misconceptions of Child Tobacco Smoke Exposure.

Introduction: Forty percent of young children worldwide are exposed to the harmful effects of tobacco smoke, predominantly by parental smoking. Little is known about why parents regularly expose their children to these risks; perhaps parents underestimate the degree of exposure. Qualitative methods were used to investigate parental perceptions of tobacco smoke exposure. Methods: Sixty-five in-depth interviews were conducted with parents of young children in smoking families in central Israel. Parents were asked to explain what "exposure to smoking" meant. Thematic analysis was performed, a conceptual model of perceptions was built, and misconceptions were identified. Results: Parents reported that exposure occurs when smoke or smokers are visible, when smoke can be smelled, felt, or inhaled, or when it "reaches" an individual. Conversely, some believed that exposure does not occur in the absence of odor, visible smoke, or smokers or if smoking occurs outdoors or in indoor ventilated environments. Proximity in space and time affected perceptions of exposure; some parents believed that smoke does not spread far but dissipates rapidly. There was some uncertainty regarding whether or not exposure was occurring. Conclusions: Awareness of child exposure to tobacco smoke among parents in this study was based on sensory perceptions in the context of the physical environment. The limited capacity of humans to perceive tobacco smoke can lead to misconceptions about exposure. In order to protect children, parents must be convinced that exposure can occur even in situations where they are unable to sense it. Implications: Parents use sensory perceptions (sight, smell, and feel) in the context of the physical environment to assess whether or not their children are exposed to tobacco smoke. Because 85% of smoke is invisible and the sense of smell is unreliable, assessments based on sensory perceptions cannot provide accurate information about the presence of tobacco smoke. In order to protect children, parents must be convinced that exposure can occur even in situations where they are unable to sense it. The scientific information summarized here about exposure in common situations should be useful in persuading parents to protect their children. Clinical Trial Registration: This study is registered as a Phase I study which is part of a larger research endeavor entitled: A program to protect young children from tobacco smoke exposure. Registration number: NCT01335178.

Smoking Behavior Change During Compulsory Military Service in Israel, 1987-2011.

INTRODUCTION: Smoking in military settings is of major concern. We aimed to assess the association between personal, family, and military factors and smoking behavior change during compulsory military service in Israel. METHODS: Participants were soldiers recruited between 1987 and 2008 who were interviewed at recruitment and reinterviewed at discharge (1987-2011) (total: 29 189; males:15 136; females:14 053). The primary outcome variables were smoking initiation during service among nonsmokers at recruitment, and cessation during service among smokers at recruitment. We examined potential predictors of change, and trends by calendar year. RESULTS: Smoking prevalence increased by 39.4% during military service (recruitment: 26.2%, discharge: 36.5%). 18.4% of nonsmoking recruits initiated smoking, and 12.4% of smoking recruits quit smoking between recruitment and discharge. There was no observed trend in initiation between 1987 and 2011. The strongest predictor of smoking initiation among nonsmokers at recruitment was smoking history (former vs. never-smoker, odds ratio (OR) [95% confidence interval [CI]]: males: 5.63 [4.63,6.85], females: 6.76 [5.27, 8.68]. Other variables had smaller effects on initiation. Females were less likely to initiate smoking than males (OR [CI]): 0.75 [0.69,0.81]. Both males and females with high military fitness levels were more likely to initiate smoking. Among women, those with lower education, with fathers with lower education, of lower socioeconomic status, and ever-users of contraceptives were more likely to initiate smoking. Cessation among males modestly increased over the years (OR [CI]): 1.03 [1.01,1.05]. CONCLUSIONS: Smoking increased substantially during mandatory military service in Israel. Former smokers were at greatly increased risk of initiation and should be targeted for relapse prevention. Military service represents a golden opportunity for tobacco control. IMPLICATIONS: Military tobacco control policy is an important contributor to longevity among service personnel, and population-wide mortality in countries with compulsory service. The increased smoking prevalence among military personnel, and increases in smoking during military service should act as a wake-up call to governments and health systems in countries lacking strong military tobacco control policies. The substantial progress in military tobacco control in the United States, which includes strong antitobacco policies for prevention of smoking initiation, aid to smokers to quit smoking, and protection of nonsmokers from tobacco smoke, should be emulated by others. Former smokers and others at high risk should be targeted for relapse prevention. The closed environment of military service provides a golden opportunity for tobacco control.

Children's Exposure to Secondhand Smoke during Ramadan in Jakarta, Indonesia.

Secondhand smoke exposure (SHS) causes a disproportionate health burden for children, yet existing smoke-free laws are often poorly enforced. We monitored air quality while observing children and adult nonsmokers present in public venues during Ramadan, a period of Muslim religious observance marked by family and social gatherings, in Jakarta, Indonesia. A repeated-measures design was used to assess indoor air quality during and after Ramadan in 43 restaurants and in five smoke-free control venues. Fine particulate matter of 2.5 microns or less (PM2.5) was sampled. The average number of children and active smokers present in each venue was also observed. PM2.5 levels were significantly higher during Ramadan (mean 86.5 µg/m³) compared with post-Ramadan (mean 63.2 µg/m³) in smoking venues (p = 0.015). During Ramadan, there were more active smokers (p = 0.012) and children (p = 0.051) observed in venues where smoking occurred, compared with the same venues post-Ramadan. Poor enforcement of the smoke-free law in Jakarta has failed to protect children from SHS exposure in public venues during Ramadan. Collaboration between the government, NGOs (such as the Indonesian Cancer Foundation (YKI) and the Smoking Control Foundation (LM3)), religious leaders, and venue owners and managers must be developed to ensure that the comprehensive smoking bans apply to all venues, and that smoke-free laws are enforced.

Effectiveness of Interventions to Reduce Tobacco Smoke Pollution in Homes: A Systematic Review and Meta-Analysis.

INTRODUCTION: Smoke-free homes can help protect children from tobacco smoke exposure (TSE). The objective of this study was to conduct a meta-analysis to quantify effects of interventions on changes in tobacco smoke pollution in the home, as measured by air nicotine and particulate matter (PM). METHODS: We searched MEDLINE, PubMed, Web of Science, PsycINFO, and Embase. We included controlled trials of interventions which aimed to help parents protect children from tobacco smoke exposure. Two reviewers identified relevant studies, and three reviewers extracted data. RESULTS: Seven studies were identified. Interventions improved tobacco smoke air pollution in homes as assessed by nicotine or PM. (6 studies, N = 681, p = 0.02). Analyses of air nicotine and PM separately also showed some benefit (Air nicotine: 4 studies, N = 421, p = 0.08; PM: 3 studies, N = 340, p = 0.02). Despite improvements, tobacco smoke pollution was present in homes in all studies at follow-up. CONCLUSIONS: Interventions designed to protect children from tobacco smoke are effective in reducing tobacco smoke pollution (as assessed by air nicotine or PM) in homes, but contamination remains. The persistence of significant pollution levels in homes after individual level intervention may signal the need for other population and regulatory measures to help reduce and eliminate childhood tobacco smoke exposure.

Parental receptivity to child biomarker testing for tobacco smoke exposure: A qualitative study.

OBJECTIVE: Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their children's exposure. Biomarkers demonstrate exposure and may motivate behavior change, but their acceptability is not well understood. METHODS: Sixty-five in-depth interviews were conducted with parents of young children, in smoking families in central Israel. Data were analyzed using thematic analysis. RESULTS: Consent to testing was associated with desire for information, for reassurance or to motivate change, and with concerns for long-term health, taking responsibility for one's child, and trust in research. Opposition to testing was associated with preference to avoid knowledge, reluctance to cause short-term discomfort, perceived powerlessness, and mistrust of research. Most parents expressed willingness to allow measurement by urine (83%), hair (88%), or saliva (93%), but not blood samples (43%); and believed that test results could motivate behavior change. CONCLUSIONS: Parents were receptive to non-invasive child biomarker testing. Biomarker information could help persuade parents who smoke that their children need protection. PRACTICE IMPLICATIONS: Biomarker testing of children in smoking families is an acceptable and promising tool for education, counseling, and motivation of parents to protect their children from TSE. Additionally, biomarker testing allows objective assessment of population-level child TSE.

Tobacco policy in Israel: 1948-2014 and beyond.

BACKGROUND: Tobacco is the only consumer product known to kill half of its users, and is a significant cause of death and disability to exposed nonsmokers. This presents a unique conundrum for modern democracies, which emphasize personal liberty, yet are obligated to protect citizens. In Israel, the death toll in 2014 from smoking is expected to reach 8000 deaths; nearly a fifth of the population smokes, and over two-thirds of the population are exposed to tobacco smoke. AIM: This paper provides an overview of tobacco policy in Israel since the inception of the State, presents the development of the National Tobacco Control Plan, and recommends future actions. METHODS: Sources for this article included the Knesset (Israeli Parliament) and Ministry of Health websites, Health Minister Reports to the Knesset on Smoking, and the scientific literature. RESULTS: Israel has an impressive record on tobacco control policy, beginning with taxation in 1952, landmark smoke-free air and marketing legislation in the early 1980's, tax increases and expansions of smoke-free air and marketing legislation in the ensuing years, and the addition of subsidized smoking cessation technologies in 2010. Until 2011, actions were taken by various organizations without formal coordination; since the passage of the National Tobacco Control Plan in 2011, the Ministry of Health has held responsibility for coordinating tobacco control, with an action plan. The plan has been partially implemented. Smoke-free air laws were expanded, but enforcement is poor. Passage of critical marketing and advertising restrictions is stalled. Requested funds for tobacco control did not materialize. RECOMMENDATIONS: In order to prevent hundreds of thousands of preventable premature deaths in the coming decades, Israel should considerably strengthen tobacco control policies to include: guaranteed funding for tobacco control; strong curbs on advertising, promotion and sponsorship of tobacco and smoking products; public education; law enforcement; protection of children from exposure to tobacco; regulation of electronic cigarettes and other alternative harm-reducing products; tobacco control research; and systematic monitoring of, and periodic updates to, the National Tobacco Control Plan. Israel should also begin discussions of Endgame scenarios, and consider abolition of tobacco, as it continues its progress towards making smoking history.

Meta-analysis of parental protection of children from tobacco smoke exposure.

BACKGROUND AND OBJECTIVE: Worldwide, roughly 40% of children are exposed to the damaging and sometimes deadly effects of tobacco smoke. Interventions aimed at reducing child tobacco smoke exposure (TSE) have shown mixed results. The objective of this study was to perform a systematic review and meta-analysis to quantify effects of interventions aimed at decreasing child TSE. METHODS: Data sources included Medline, PubMed, Web of Science, PsycNet, and Embase. Controlled trials that included parents of young children were selected. Two reviewers extracted TSE data, as assessed by parentally-reported exposure or protection (PREP) and biomarkers. Risk ratios and differences were calculated by using the DerSimonian and Laird random-effects model. Exploratory subgroup analyses were performed. RESULTS: Thirty studies were included. Improvements were observed from baseline to follow-up for parentally-reported and biomarker data in most intervention and control groups. Interventions demonstrated evidence of small benefit to intervention participants at follow-up (PREP: 17 studies, n = 6820, relative risk 1.12, confidence interval [CI] 1.07 to 1.18], P < .0001). Seven percent more children were protected in intervention groups relative to control groups. Intervention parents smoked fewer cigarettes around children at follow-up than did control parents (P = .03). Biomarkers (13 studies, n = 2601) at follow-up suggested lower child exposure among intervention participants (RD -0.05, CI -0.13 to 0.03, P = .20). CONCLUSIONS: Interventions to prevent child TSE are moderately beneficial at the individual level. Widespread child TSE suggests potential for significant population impact. More research is needed to improve intervention effectiveness and child TSE measurement.

Performance of aseptic technique during neuraxial analgesia for labor before and after the publication of international guidelines on aseptic technique.

BACKGROUND: Aseptic technique and handwashing have been shown to be important factors in perioperative bacterial transmission, however compliance often remains low despite guidelines and educational programs. Infectious complications of neuraxial (epidural and spinal) anesthesia are severe but fortunately rare. We conducted a survey to assess aseptic technique practices for neuraxial anesthesia in Israel before and after publication of international guidelines (which focused on handwashing, jewelry/watch removal and the wearing of a mask and cap). METHODS: The sampling frame was the general anesthesiology workforce in hospitals selected from each of the four medical faculties in Israel. Data was collected anonymously over one week in each hospital in two periods: April 2006 and September 2009. Most anesthesiologists received the questionnaires at departmental staff meetings and filled them out during these meetings; additionally, a local investigator approached anesthesiologists not present at these staff meetings individually. Primary endpoint questions were: handwashing, removal of wristwatch/jewelry, wearing mask, wearing hat/cap, wearing sterile gown; answering options were: "always", "usually", "rarely" or "never". Primary endpoint for analysis: respondents who both always wash their hands and always wear a mask ("handwash-mask composite") - "always" versus "any other response". We used logistic regression to perform the analysis. Time (2006, 2009) and hospital were included in the analysis as fixed effects. RESULTS: 135/160 (in 2006) and 127/164 (in 2009) anesthesiologists responded to the surveys; response rate 84% and 77% respectively. Respondents constituted 23% of the national anesthesiologist workforce. The main outcome "handwash-mask composite" was significantly increased after guideline publication (33% vs 58%; p = 0.0003). In addition, significant increases were seen for handwashing (37% vs 63%; p = 0.0004), wearing of mask (61% vs 78%; p < 0.0001), hat/cap (53% vs 76%; p = 0.0011) and wearing sterile gown (32% vs 51%; p < 0.0001). An apparent improvement in aseptic technique from 2006 to 2009 is noted across all hospitals and all physician groups. CONCLUSION: Self-reported aseptic technique by Israeli anesthesiologists improved in the survey conducted after the publication of international guidelines. Although the before-after study design cannot prove a cause-effect relationship, it does show an association between the publication of international guidelines and significant improvement in self-reported aseptic technique.