Lorraine Craig

Risk management frameworks for human health and environmental risks

A comprehensive analytical review of the risk assessment, risk management, and risk communication approaches currently being undertaken by key national, provincial/state, territorial, and international agencies was conducted. The information acquired for review was used to identify the differences, commonalities, strengths, and weaknesses among the various approaches, and to identify elements that should be included in an effective, current, and comprehensive approach applicable to environmental, human health and occupational health risks.

Air Pollution and Public Health: A Guidance Document for Risk Managers

This guidance document is a reference for air quality policymakers and managers providing state-of-the-art, evidence-based information on key determinants of air quality management decisions. The document reflects the findings of five annual meetings of the NERAM (Network for Environmental Risk Assessment and Management) International Colloquium Series on Air Quality Management (2001–2006), as well as the results of supporting international research. The topics covered in the guidance document reflect critical science and policy aspects of air quality risk management including i) health effects, ii) air quality emissions, measurement and modeling, iii) air quality management interventions, and iv) clean air policy challenges and opportunities.

Implementation of key demand-reduction measures of the WHO Framework Convention on Tobacco Control and change in smoking prevalence in 126 countries: an association study

BACKGROUND The WHO Framework Convention on Tobacco Control (WHO FCTC) has mobilised efforts among 180 parties to combat the global tobacco epidemic. This study examined the association between highest-level implementation of key tobacco control demand-reduction measures of the WHO FCTC and smoking prevalence over the treatys first decade. METHODS We used WHO data from 126 countries to examine the association between the number of highest-level implementations of key demand-reduction measures (WHO FCTC articles 6, 8, 11, 13, and 14) between 2007 and 2014 and smoking prevalence estimates between 2005 and 2015. McNemar tests were done to test differences in the proportion of countries that had implemented each of the measures at the highest level between 2007 and 2014. Four linear regression models were computed to examine the association between the predictor variable (the change between 2007 and 2014 in the number of key measures implemented at the highest level), and the outcome variable (the percentage point change in tobacco smoking prevalence between 2005 and 2015). FINDINGS Between 2007 and 2014, there was a significant global increase in highest-level implementation of all key demand-reduction measures. The mean smoking prevalence for all 126 countries was 24·73% (SD 10·32) in 2005 and 22·18% (SD 8·87) in 2015, an average decrease in prevalence of 2·55 percentage points (SD 5·08; relative reduction 10·31%). Unadjusted linear regression showed that increases in highest-level implementations of key measures between 2007 and 2014 were significantly associated with a decrease in smoking prevalence between 2005 and 2015). Each additional measure implemented at the highest level was associated with an average decrease in smoking prevalence of 1·57 percentage points (95% CI -2·51 to -0·63, p=0·001) and an average relative decrease of 7·09% (-12·55 to -1·63, p=0·011). Controlling for geographical subregion, income level, and WHO FCTC party status, the per-measure decrease in prevalence was 0·94 percentage points (-1·76 to -0·13, p=0·023) and an average relative decrease of 3·18% (-6·75 to 0·38, p=0·079). This association was consistent across all three control variables. INTERPRETATION Implementation of key WHO FCTC demand-reduction measures is significantly associated with lower smoking prevalence, with anticipated future reductions in tobacco-related morbidity and mortality. These findings validate the call for strong implementation of the WHO FCTC in the WHOs Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013-2020, and in advancing the UNs Sustainable Development Goal 3, setting a global target of reducing tobacco use and premature mortality from non-communicable diseases by a third by 2030. FUNDING Health Canada, Canadian Institutes of Health Research, Ontario Institute for Cancer Research and Canadian Cancer Society Research Institute.

Health and Air Quality: Directions for Policy-Relevant Research

The NERAM International Colloquia series is a program of five annual meetings involving scientists, regulators, industry representatives, and other stakeholder groups to improve the linkage between emerging scientific evidence on the population health impacts of exposure to particulate matter and clean air policy decisions. Health and Air Quality 2001, the first meeting in the colloquium series, focused on the findings of prospective cohort studies of particulate air pollution and mortality and implications for risk management. A further objective of the colloquium was to identify research directions to reduce information gaps and uncertainties faced by policy makers. This article discusses priority themes for future research to generate evidence in support of policy decisions to improve air quality and population health. These research themes include development of population health indicators to characterize the public health burden of air pollution; individual exposure and outcome studies to the currently available database on the association between air pollution and adverse health effects; identification of sensitive subpopulations; techniques to assess the independent effects of individual pollutants on population health; comparative risk assessment; methods for characterization and communication of uncertainty in risk estimates; effectiveness of policy interventions to guide allocation of limited population health protection resources; improved predictions of the benefits of interventions through appropriate economic analyses: targeted interventions; and approaches for effective stakeholder engagement in risk management policy decisions. Future meetings in the NERAM Colloquium series will provide a forum for discussion of the current state of knowledge and policy implications of findings associated with these key research themes.

Air Quality Risk Assessment and Management

This article provides (1) a synthesis of the literature on the linkages between air pollution and human health, (2) an overview of quality management approaches in Canada, the United States, and the European Union (EU), and (3) future directions for air quality research. Numerous studies examining short-term effects of air pollution show significant associations between ambient levels of particulate matter (PM) and other air pollutants and increases in premature mortality and hospitalizations for cardiovascular and respiratory illnesses. Several well-designed epidemiological studies confirmed the adverse long-term effects of PM on both mortality and morbidity. Epidemiological studies also document significant associations between ozone (O3), sulfur (SO2), and nitrogen oxides (NOx) and adverse health outcomes; however, the effects of gaseous pollutants are less well documented. Subpopulations that are more susceptible to air pollution include children, the elderly, those with cardiorespiratory disease, and socioeconomically deprived individuals. Canada-wide standards for ambient air concentrations of PM2.5 and O3 were set in 2000, providing air quality targets to be achieved by 2010. In the United States, the Clean Air Act provides the framework for the establishment and review of National Ambient Air Quality Standards for criteria air pollutants and the establishment of emissions standards for hazardous air pollutants. The 1996 European Unions enactment of the Framework Directive for Air Quality established the process for setting Europe-wide limit values for a series of pollutants. The Clean Air for Europe program was established by the European Union to review existing limit values, emission ceilings, and abatement protocols, as set out in the current legislation. These initiatives serve as the legislative framework for air quality management in North America and Europe.

Outdoor smoking behaviour and support for outdoor smoking restrictions before and after France's national smoking ban.

BACKGROUND On January 1, 2008, the French government implemented a national ban on indoor smoking in hospitality venues. Survey results indicate the indoor ban has been successful at dramatically reducing indoor smoking; however, there are reports of an increased number of outdoor hospitality spaces (patios) where smoking can take place. This study sought to understand if the indoor ban simply moved smoking to the outdoors, and to assess levels of support for smoking restrictions in outdoor hospitality settings after the smoke-free law. METHODS Telephone interviews were conducted among 1067 adult smokers before and after the 2008 indoor ban as part of the International Tobacco Control (ITC) France Survey. Among other topics, this survey measures how the smoking ban has influenced smoking behaviour relevant to outdoor sections of hospitality venues. In addition, 414 non-smoking adults and 164 respondents who had quit smoking between waves were also asked about support for outdoor smoking restrictions. RESULTS Reported smoking outdoors at cafés/pubs/bars increased from 33.6% of smokers at Wave 1 to 75.9% at Wave 2. At restaurants, smoking outdoors increased from 28.9% to 59.0%. There was also an increase in reported non-smoking for both visits to cafés/pubs/bars, and restaurants from 13.4% to 24.7%, and 30.4% to 40.8% respectively. The majority of smokers (74.5%), non-smokers (89.4%) and quitters (74.0%) support a partial or complete ban on smoking in outdoor areas of restaurants. CONCLUSION The indoor smoking ban moved smoking to outdoor spaces; however, the ban is also associated with increased non-smoking behaviour. The majority of respondents support outdoor smoking restrictions in patio environments.

Evaluating the Effectiveness of France's Indoor Smoke-Free Law 1 Year and 5 Years after Implementation: Findings from the ITC France Survey.

France implemented a comprehensive smoke-free law in two phases: Phase 1 (February 2007) banned smoking in workplaces, shopping centres, airports, train stations, hospitals, and schools; Phase 2 (January 2008) banned smoking in hospitality venues (bars, restaurants, hotels, casinos, nightclubs). This paper evaluates France’s smoke-free law based on the International Tobacco Control Policy Evaluation Project in France (the ITC France Project), which conducted a cohort survey of approximately 1,500 smokers and 500 non-smokers before the implementation of the laws (Wave 1) and two waves after the implementation (Waves 2 and 3). Results show that the smoke-free law led to a very significant and near-total elimination of observed smoking in key venues such as bars (from 94–97% to 4%) and restaurants (from 60–71% to 2–3%) at Wave 2, which was sustained four years later (6–8% in bars; 1–2% in restaurants). The reduction in self-reported smoking by smoking respondents was nearly identical to the effects shown in observed smoking. Observed smoking in workplaces declined significantly after the law (from 41–48% to 18–20%), which continued to decline at Wave 3 (to 14–15%). Support for the smoke-free laws increased significantly after their implementation and continued to increase at Wave 3 (p<.001 among smokers for bars and restaurants; p<.001 among smokers and p = .003 for non-smokers for workplaces). The findings demonstrate that smoke-free policies that are implemented in ways consistent with the Guidelines for Article 8 of the WHO Framework Convention on Tobacco Control (WHO FCTC) lead to substantial and sustained reductions in indoor smoking while also leading to high levels of support by the public. Moreover, contrary to arguments by opponents of smoke-free laws, smoking in the home did not increase after the law was implemented and prevalence of smoke-free homes among smokers increased from 23.2% before the law to 37.2% 5 years after the law.

Tobacco control in Europe: A deadly lack of progress

igarettes are uniquely dangerous, killing half of all those who regularly use them and damaging the health of those who breathe in users’ smoke, particularly children. Just under a third of European adults currently smoke, and smoking has become increasingly associated with poverty, contributing significantly to widening health inequalities across the EU. In 2004, the ASPECT report, a comprehensive review of tobacco use and tobacco control policies in the EU, found that tobacco use caused well over half a million deaths in Europe annually and on top of that constituted a huge economic burden, estimated conservatively at E98-130 billion a year. 1 This review also identified that whilst some European countries were observing declines in tobacco use and mortality, in other countries tobacco use was still increasing, particularly among women. The ASPECT report identified 43 recommendations to combat the epidemic, covering tobacco control policy, interventions and research. Yet to date, few of these recommendations have been implemented, and as a result, future prospects for curbing the smoking epidemic across Europe are currently very bleak. On the optimistic side, in 2003, the world’s first public health treaty, the World Health Organisation’s Framework Convention on Tobacco Control (FCTC) came into force in recognition of the smoking pandemic and the power of the major transnational tobacco companies to push their deadly products. 2 The FCTC sets out supply and demand strategies to reduce tobacco use and has since been ratified by all EU countries (except the Czech Republic) and the European Union. The FCTC represents a unique and historic opportunity to fight the pandemic and collectively reduce the public health burden caused by tobacco and should therefore herald the way to faster progress in reducing smoking. However, the FCTC will only fulfil its potential if it is implemented in the most effective way and there is strong evidence that this is currently not the case. The Tobacco Control Scale (TCS) was developed by Joossens and Raw 3 to monitor the implementation of tobacco control

Can the Dutch Government really be abandoning smokers to their fate

www.thelancet.com Vol 379 January 14, 2012 121 Authors’ reply Men were taught to tighten both their deep and superfi cial muscles by imagining stopping the fl ow of urine, preventing wind from escaping, and observing penile and testicular lift. Pelvic-fl oor muscle training was not used to strengthen the external sphincter, but to compensate for its reduced function by preventing the passage of urine using the pelvic fl oor muscles to constrict the urethra at or below the level of the external sphincter. Our outcome of interest was whether this was successful in preventing urine leakage. Our pragmatic trial was designed to assess the eff ectiveness and costeff ectiveness of routine physiotherapy services typically available in the National Health Service in the UK and other publicly funded health-care systems, in contexts where inform ation about pelvic fl oor muscle training is widely available. The study was not intended to assess the effi cacy of long-term and individually tailored instruction, nor the use of highly specialised physiotherapists. We did show an increase in pelvic-fl oor muscle strength and increased practice of contractions, but whether more frequent or more specialised training might be more eff ective remains unclear. We used the fi rst two questions of the ICIQ-UI short-form questionnaire to defi ne “any urinary incontinence”, not taking into account the third question which captures the eff ect on quality of life. We would argue that any urine loss is meaningful to patients. We justifi ed our choice of a subjective outcome measure as one that is relevant to men, and judged by them to be aff ecting their quality of life. We do not agree that “objective” measures such as the pad test are more relevant to men, and in addition these are very variable and hence unreliable. We accounted for the degree of incontinence by accepting all men with urinary incontinence into the trial but analysing “more severe” urinary incontinence separately. In fact, more than 90% of our participants had “severe urinary incontinence” at baseline (defi ned as losing a moderate to large amount of urine at least once per day), and half of them improved to having only “mild urinary incontinence” by 12 months. Our trial was pragmatic in that it refl ected the range of prostate surgery available in a large number of typical UK centres, including high-volume and low-volume centres. There are many factors that aff ect outcome after radical prostatectomy including tumour factors, patient factors, surgeon factors, and centre factors. Although all surgeons attempted nerve-sparing techniques, this was not always possible. Some men had laparoscopic or perineal surgery rather than open abdominal procedures. The panel in our paper was intended to place the MAPS trial in the context of other published studies. MAPS is the largest trial of formal one-to-one pelvicfl oor muscle training for the treatment of urinary incontinence in men after radical prostatectomy and the only such study in men after transurethral resection of the prostate. A 1999 Cochrane review had highlighted the lack of reliable evidence on which treatment decisions could be based. The most recent search of the literature identifi ed at least 16 more trials, of which only one (by Manassero and colleagues) had 12-month outcome data in the relevant population. Comments were made specifi cally about the Manassero trial only because it was relatively recent and therefore was not included in the last published review. We explained the eff ect of adding the Manassero trial to the Cochrane meta-analysis and highlighted possible reasons for these eff ects, one of which was the diff erential dropout rate, which can be regarded as a source of bias in the context of meta-analysis. Finally, the small trial by Centemero and colleagues might be regarded as prevention rather than treatment of urinary incontinence, and hence did not address the same population of men. Nevertheless, we considered that there was a high risk of bias because outcomes were assessed by those who did the interventions.

Regulatory and Nonregulatory Strategies for Improving Children's Environmental Health in Canada

Epidemiological and toxicological studies established positive associations between environmental hazards and adverse child health outcomes, including cancer, learning disabilities, behavioral problems, developmental effects, low birth weight, and birth defects. The economic and societal costs associated with childrens environmental health disorders were estimated to be substantial. The existence of knowledge gaps, lack of capacity, and the jurisdictional overlap of childrens environmental health issues are some of the barriers that impede effective policy decision making. To improve childrens environmental health and reduce economic and societal costs, current legislative frameworks could implement a series of amendments. The main federal, provincial, and municipal legislation used to protect children in Canada, either explicitly or implicitly, is reviewed. Recommendations for improving the existing framework for protecting and strengthening childrens environmental health are proposed.