Divisions of population health: quantum leap forward or rearranging the deckchairs?

Objectives: To describe the reasons for the formation of divisions of population health in NSW, their functional units, how they might be evaluated, and some future challenges; to stimulate critical appraisal of the divisions.
Methods: Personal observation; review of documentation and organisational charts.
Results: Area health services (AHSs) were established in NSW in 1986; there are now 17. Divisions of population health attempt to overcome the marginalisation and fragmentation that often characterise population health workers within AHSs. Divisions aim to strengthen an AHS's capacity to meet its legislated responsibility to protect and promote the health of the local population. Each of the 13 divisions established since 1994 contains a different mix of services. Public health, health promotion and health services planning units are most commonly included in divisions. Formal evaluations of organisational structures are not common in health services. Evaluations of divisions of population health should focus on their success at: creating organisational structures and processes which are conducive to the implementation of population health strategies; improving health outcomes; and improving the personal, social and environmental preconditions for health.
Conclusions: Establishing divisions of population health has highlighted the lack of evidence regarding the effectiveness of different organisational structures for delivering population health services.
Implications: Greater effort is needed to evaluate existing organisational structures and to develop and implement optimal structures for population health services.     

Hospital closure: Phoenix, Hydra or Titanic?

Very little has been published about the effects of hospital closure in terms of the service, financial or management issues of the process. Attempts through a case-study format to redress the balance and as such represents the reflections of practitioners who have recently undergone the experience of hospital closure and the often neglected issues arising both during and after the process.     

The analysis of tobacco consumption in Croatia--are we successfully facing the epidemic?

Tobacco is the largest cause of morbidity and mortality. The aim of this study is to analyse several health and economically related indicators of tobacco consumption: smoking prevalence, standardized death rates (SDRs) from lung cancer and the proportion of GDP spent on tobacco in Croatia and other transitional countries--the Czech Republic, Slovakia, Poland, Hungary, Slovenia, Romania, and Bulgaria. The overall smoking prevalence in Croatia decreased by 5.2% during 1994-2005, more among females (-9.9%) than males (-0.3%). There is no significant difference in the smoking prevalence between Croatia (27.4%) and other countries. However, 33.8% of Croatian males smoked during 2002-2005, more than in Romania and the Czech Republic, and less than in Hungary and Poland. The prevalence of female smoking (21.7%) in Croatia is similar to the female smoking prevalence in Poland, the Czech Republic, and Hungary, but male smoking is predominant in all countries. The proportion of smokers among youth is above 20% and it is the highest in the Czech Republic (29.7%), followed by Hungary (26.7%), Slovenia (24.9%), Croatia (24.1%), and Poland (21.5%). The proportion of smokers among girls is higher than among boys in Slovenia, Hungary, the Czech Republic, and Croatia, contrary to Slovakia, Bulgaria, and Poland where boys smoke slightly more. There is no significant difference between the prevalence of smoking among girls in Croatia and Bulgaria, Poland, the Czech Republic, Hungary, Slovenia, and Slovakia. According to the SDR from lung cancer in males (70.3/100,000), Croatia is ranked high assuming the 3rd place, after Hungary (99.7) and Poland (72.0). With a SDR of 15.9/100,000 for females, Croatia is ranked slightly better--5th place. Tobacco consumption continues to be a major public health problem in transitional countries. Croatia conducted several campaigns and programmes in the past. However, results reveal that current anti-tobacco strategies are ineffective in reducing the smoking prevalence among men and youth. Men do not smoke less than a decade ago and, despite the observed decline among women, increasing trends are observed among teenage girls. Croatia should apply a comprehensive approach that would include raising awareness of health risks, restriction of smoking in public places, higher taxing, implementing stricter bans on advertising and promotion of tobacco as well as supporting smoking cessation. This last measure is believed to bring about some results in the medium term in targeted population groups, provided that it is supported by all health professionals. Otherwise, we may expect progress at the population level in the field of social stigmatization of smoking and wider intolerance to second-hand smoke. The full impact of smoking on the population health is yet to be seen and in the future it will undoubtedly remain one of the major contributors to the poor public health situation in Croatia.     

Evaluating the tobacco settlement damage awards: too much or not enough?

OBJECTIVES: This study compared the present economic value of the 1998 tobacco settlement with the present economic value of the damages attributable to tobacco. METHODS: The 1987 National Medical Expenditure Survey was used to estimate the smoking attributable fraction (SAF) of medical expenditures. SAFs were then applied to Medicaid and other expenditures. RESULTS: Settlement payments covered only 40% of Medicaid treatment costs already incurred and only 30% of past and projected future Medicaid costs. Excess medical expenditures for all other payment sources were roughly comparable to those incurred by Medicaid. CONCLUSIONS: Although the settlement may reduce future smoking prevalence rates by limiting the ability of tobacco companies to promote smoking and by raising cigarette prices, euphoria over the huge settlement funds should be balanced by a sober comparison with the even larger damage amounts.     

Nicotine and tobacco dependence: normalization or stimulation?

Nicotine and tobacco use produces mixed stimulant and depressant effects on various brain functions in animals and human beings. Results of electroencephalographic studies indicate that some tobacco smokers after 10-24 h of tobacco deprivation exhibit a decrease in dominant alpha rhythm, which, immediately after smoking, increases toward that of nonsmokers. This is evidence that tobacco smoking in smokers involves normalization of brain activity. Results of other studies of acute smoking effects in smokers show an increase in dominant alpha rhythm greater than that of nonsmokers. This is evidence that tobacco smoking produces stimulation of brain activity in smokers.     

Public health response to the obesity epidemic: too soon or too late?

Public health actions in response to new threats are often taken despite uncertainty about the efficacy of the action. The challenge, then, is to make ongoing judgments about whether actions are taken too soon, before a sufficient understanding of the efficacy of interventions is known, or too late, after much of the prevention potential is lost. The ongoing obesity epidemic presents exactly this type of challenge. General lessons learned from the AIDS and tobacco epidemics as well as others can be useful now as we contemplate options for reversing the ongoing epidemic of obesity in the United States. In this article we briefly review current evidence regarding the efficacy of obesity interventions in both clinical and community settings. We conclude that although little direct evidence is available on the efficacy of interventions for the obesity epidemic, there are some reasonable options derived from experience with other public health epidemics that can contribute to the solution of the obesity problem.     

Smokeless tobacco use: harm reduction or induction approach?

BACKGROUND: Smokeless tobacco (ST) substitution for cigarettes as a method to reduce harm has been actively debated. Use of ST as a smoking cessation method or as a means to reduce cigarettes has been proposed. The impact of using ST in these ways is relatively unknown. METHODS: A review of the different issues and studies related to using smokeless tobacco as a method to reduce tobacco toxin exposure and harm is presented. RESULTS: The toxicity of the product itself varies by brand of ST and across countries. Of the existing studies, comparisons of consequences between cigarettes and ST show that cigarette smoking produces more negative health effects, is likely to have a higher addiction potential and more severe withdrawal, and leads to a higher rate of relapse than ST use. On the other hand, ST use facilitates the use of cigarettes, which is a deadly tobacco product. Additionally, ST is not a harmless product, and a less harmful product, medicinal nicotine, is available as an effective treatment approach. Furthermore, ST products are not under the same regulatory scrutiny as medicinal nicotine products. CONCLUSIONS: Considerably more research and product regulation is necessary prior to considering smokeless tobacco as a harm reduction method.     

Local governments’ dependence on tobacco tax revenue: a?deterrent to tobacco control in the Republic of Korea

Objective

To investigate, in the Republic of Korea, whether local governments’ participation in an anti-smoking programme supported by the National Health Promotion Fund in 2002–2003 was related to the percentage of local tax revenue comprised by the tobacco consumption tax (TCT).

Methods

Using financial and administrative data on 163 municipalities, the authors estimated logit models of local governments’ participation in the anti-smoking programme as a function of the proportion of local tax revenue that came from the TCT and a set of control variables, namely local socioeconomic characteristics and the size of the staff in the local public health centre (PHC).

Findings

Local governments that derived a greater percentage of their local tax revenue from the TCT, particularly those that ranked in the upper fourth in terms of this percentage, were less likely to participate in the anti-smoking programme. Insufficient staff in the PHC was also found to be associated with lower participation in the anti-smoking programme.

Conclusion

Local governments’ dependence on revenue from the TCT may be a deterrent to tobacco control in the Republic of Korea.