Introduction
Currently, 1.3 billion people around the world use tobacco, and 4.9 million people die from tobacco use every year. Half of all current tobacco users will eventually die from tobacco-related illnesses. By 2030, the World Bank predicts that smoking will kill about one in six adults globally per year (1). Although almost 70% of these deaths occur in developing nations, tobacco use is still a major health problem in Europe. It is the second largest cause of death and the leading preventable cause of death worldwide. Governments and legislators have a duty to try to prevent these deaths but society must also be involved, with health professionals having a special and prominent role to play in tobacco control. They have the trust of the population and the media, and they can reach a vast range of social, economic and political arenas. As health professionals are in contact with a high percentage of the population, they have the opportunity to help people change their behaviour. They can give advice, guidance and answers to questions related to the consequences of tobacco use, help patients to stop smoking and advise and warn children and adolescents about the dangers of smoking. Studies have shown that even brief counselling by health professionals on the dangers of smoking and the importance of quitting is one of the most cost-effective methods of reducing smoking (2).

Health professionals can intervene at many levels. At individual level, they can educate the population on the harms of tobacco use, and how to overcome addiction. Guidelines have been issued advising health professionals how to do this (3). At community level, they can initiate and support efforts to promote smoke-free work places and extend the availability of resources aimed at helping those who wish to stop smoking. Finally, at society level, they can add their voice and weight to national and global tobacco control efforts, lobbying for taxation measures and anti-smoking legislation, and promoting initiatives such as World No Tobacco Day and the WHO Framework Convention on Tobacco Control (WHO FCTC). For example, a Europe-wide petition was recently launched by health professionals, demanding simple access to smoking cessation services for smokers, the total protection of non-smokers against tobacco smoke and the implementation of the WHO framework convention on tobacco control.

In general, health professionals should be the example that a healthy society reflects upon. Organisations of health professionals can show leadership and become role models for other professional organisations and society. By promoting smoke-free workplaces and a smoke-free culture, they should set an example for their patients to follow.

Cross European Comparison
Obviously, one major gesture towards setting a good example is banning the sale of tobacco products within healthcare premises. A number of EU countries, such as Poland, Greece, Spain and Estonia now prohibit the sale and promotion of tobacco products in these institutions. The International Network of Health Promoting Hospitals and the European Network of Smoke-Free Hospitals, which operate in most member states, are active in making health services smoke-free, providing smoking cessation services and encouraging health professionals themselves to stop smoking. Health professionals from Malta have stated that the introduction of smoke-free public places legislation has helped to increase the number of people quitting smoking (4). With this in mind, many countries have either implemented or will very shortly implement bans on smoking in workplaces, public transport and public places.

Both Malta and Sweden have umbrella anti-tobacco organisations of health professionals comprising doctors, dentists, nurses, teachers, pharmacists and psychologists. One such organisation has, together with The Ministry of Health in Malta, established a support system to help quitters by providing access to smoking cessation clinics. The Health Promotion Department organises educational lectures and training to inform professionals on the continually changing challenges of smoking cessation. In Sweden, groups such as European Nurses & Midwives Against Tobacco and Health Professionals Against Tobacco address tobacco control issues, such as policy, opinion building and professional development. Organisations such as these also empower health professionals to adopt stronger tobacco-free policies and to build skills to support patients in the long process of quitting smoking. Over two-thirds of dentists in both Sweden and Finland stated that they feel it is their duty to encourage their patients to quit smoking (5). In the UK, the NHS has set up an extremely effective and comprehensive Stop Smoking Service. This service provides counselling and support to smokers wanting to quit smoking.

Health professionals need to update their knowledge and skills throughout their careers to maintain their competence. Undergraduate and ongoing post-qualification training is seen as an effective measure in the counselling of people wishing to quit smoking. However, such training varies vary across Europe. In Estonia, medical practitioners are trained to counsel smokers, and Estonia aims to have at least one counselling office staffed with professional counsellors in each of its 15 counties by the end of 2005. Since 1995, all students at Lithuania"s principal medical university receive lectures on smoking prevention and how to help those wishing to quit. Germany sees the importance of increasing the awareness of doctors and other health professionals in the treatment of tobacco addiction, where there is perceived to be a lack of experience in smoking cessation techniques.

Public awareness and education, especially among children, adolescents and young adults, is considered vital in anti-smoking policy, and here, health professionals play an extremely important role. Extra priority is being given to these groups in Greece, where health professional inform children about the addictive nature and health hazards of tobacco consumption. In Sweden, Spain and Slovakia, health professionals have been working with schools to enrich the curriculum by including tobacco control and the promotion of good health, although in Spain and Slovakia this is still inconsistent and not universal. Public awareness campaigns aimed at young people and pregnant women have been conducted in Cyprus, and in Estonia the National Institute for Health Development has implemented an innovative competitive approach in schools, where peer-pressure makes quitting smoking difficult for school children.

Obstacles to the Success of Programmes
Despite these proactive measures to tackle tobacco addiction, in numerous European countries two of the principal obstacles to an effective anti-smoking policy are financial. One is the level of taxation on tobacco products and the other is the difference in the cost to the individual of obtaining treatment.

The World Health Organisation and World Bank estimate that a 10% rise in cigarette prices would motivate about 42 million people to quit smoking in the world (6). The taxes levied on tobacco products can result in enormous relative price differences for cigarettes between EU countries. For example, cigarettes bought in Luxembourg can be up to three times cheaper than cigarettes bought in the UK (7). As a consequence, Luxembourg attracts an enormous number of smokers from surrounding nations. In France, an increase in prices over the last few years has seen the number of smokers wanting to quit increase enormously. Health professionals can use their prominent role to lobby governments to consider changes to taxation systems.

The cost of obtaining treatment for tobacco addiction can be a major obstacle to cessation treatments. Smoking is most prevalent among those with the most limited resources. The cost of cessation treatment should therefore not be prohibitive. Currently, there is no consensus concerning treatment cost across Europe. For example, in Malta, smoking cessation clinics are easily accessible to everyone and are free, encouraging participation. In the UK, the NHS has made smoking cessation aids, including nicotine replacement therapy, available on prescription, which makes them free for the elderly and people on low incomes. In countries such as Spain, Germany and Slovakia, pharmacological help is not free. The consequences are that, in Germany for example, only 25% of doctors enquire into a patient’s smoking status and less than 5% advise patients to quit smoking. This situation has also been attributed to a lack of support for doctors and a lack of time and resources for other health professionals in the treatment of tobacco dependence. Lack of resources has been cited as a major problem in nicotine addiction programmes in Slovakia despite the high success rates of various projects. Relapse levels can also be high, due to a lack of psychological counselling support for smokers trying to quit.

Finally, public awareness and research are not consistent among EU countries. Although research projects into the effectiveness of cessation programmes are about to start in Spain, and projects are soon to be started in Cyprus, there is often a lack of data for the efficacy of such projects.

Summary
Health professional play an extremely important role in reducing smoking. Umbrella organisations of health professionals have a positive impact on policy decisions and opinion building, and these organisations ensure the continuing education and training of health professionals. However, these organisations cannot operate without the support of the Member States. Therefore, health professionals should be encouraged to give up smoking themselves and in their efforts to convince the general public to seek help to stop smoking, and to get the appropriate national and international bodies to fund anti-smoking initiatives.

Information on the new  "HELP - For a life without tobacco" EU anti-smoking campaign and on the activities of the European Union in the field of tobacco control  can be found on the Commission"s  website , at http://europa.eu.int/comm/health/.../tobacco_en.htm

Comments:
- This press release has been compiled based on the expertise provided by the members of the European Network for Smoking Prevention (May 2005).
- “The views expressed may not in any circumstances be regarded as stating an official position of the European Commission"
- Links and sources are to be part of the body of the text.
- As part of the new anti-smoking campaign “HELP – For a life without tobacco” launched by the European Commission, regular press releases will be sent out (from April till November) to provide media with relevant health-related information in order to accompany, prolong and intensify the “HELP” campaign measures.