By 2035, no child in Rotterdam should be exposed to tobacco smoke. That is the mission of policy makers and scientists inside and outside the EUR. Among them Jasper Been, paediatrician at Erasmus MC and Paul Kocken, health scientist at the Erasmus School of Social and Behavioural Sciences (ESSB).
Who are the most vulnerable when it comes to tobacco?
BEEN: "As a paediatrician, I naturally think first and foremost of children. We should protect them much more, already during pregnancy. If the mother-to-be smokes, toxic substances such as carbon monoxide go straight to the baby via the umbilical cord. These substances can cause a kind of chronic lack of oxygen. The risk of premature birth, disease or congenital abnormality is significantly higher in babies born to mothers who smoke. But smoking is of course unhealthy for everyone. Around 8 million people worldwide die each year from the effects of tobacco. In about one in eight cases this is caused by second-hand smoke, i.e. by inhaling the smoke of others. Children are often unable to get away when smoking is in their vicinity. This can give them asthma or respiratory infections. They are the ones who deserve our protection."
Are there specific groups that smoke?
KOCKEN: "An unhealthy lifestyle, including smoking, is more common in the lower social classes. That is understandable. If you can barely afford the costs of your children's education and you live in a poor house in an unsafe neighbourhood, you have more pressing concerns. Research has shown that financial stress is an impeding factor in quitting smoking. In addition, tobacco is highly addictive."
BEEN: "This also has a physiological reason. The tobacco industry has for years added all kinds of substances to cigarettes in order to increase dependency. Those substances cause a sensation in your brain that makes you think: I must have more of this."
KOCKEN: "Yes, the industry has known for a long time how deadly its products were. By the way, our focus is not only on poor neighbourhoods. A large group of students also smoke, although not all of them daily. Research by the Trimbos Institute shows that among higher educated people many 20-24 year olds smoke occasionally, but the group of 25-30 year olds smokes more daily. Possibly this is also an outlet for stress."
Isn't quitting smoking just a choice?
KOCKEN: "From health psychology we know that only a limited part of human behaviour is conscious. We largely act from automatisms. Lighting up a cigarette is a moment of rest, something that offers comfort. You don't think about it. Besides all the worries that many people in deprived neighbourhoods have, there is too little room in the brain to work on a considered change of behaviour. We are doing research on this. One theory is that if we alleviated their problems financially, they would start to think more consciously about their smoking behaviour."
"It's hard to imagine, but when I was doing my internship, people were still smoking in the hospital."
Jasper Been
Paediatrician, Erasmus MC
What role does the environment play?
KOCKEN: "Whether you smoke or not also depends on the people around you. If your parents or friends smoke, you may find it 'normal' for you to light up a cigarette too."
"It's also about the standard we set as a society. It's hard to imagine, but when I was doing my internship, people were still smoking in the hospital. In 2004, we as a society said: no smoking at work and in public places. Our research has shown that this has improved children's health. Fewer children suffer from lung diseases and even the number of premature births has decreased. A few years ago, Erasmus MC, together with our neighbours from the Rotterdam University of Applied Sciences, took the initiative to create a smoke-free outdoor area. A legal ban did not succeed, but we put up signs asking people not to smoke in the vicinity of the hospital. Staff and patients were also offered the Stop Smoking course. Students talked to smokers on the premises. They often did not react negatively at all and were willing to change their behaviour. The number of smokers fell by half. Soft measures are often effective."
In behavioural psychology, this is called nudging, right?
KOCKEN: "Nudging is stimulating someone in a subtle way to change their behaviour. A good example is the stamp card we use to encourage people to follow the Grip and Health course and motivate them to stop smoking. At each visit they receive a stamp, and if the card is full, a bag of healthy groceries. In addition to the course and the nudging techniques, we use financial buddies: volunteers who are trained to help people identify the bottlenecks and become more self-reliant. Of course, buddies do not take away the debts. But they teach their clients how to deal with stress in combination with financial matters. The precarious thing is that people do not talk easily about their money worries, also out of shame. That is why the buddies prefer to come from the community, but not too close. After the Grip and Health course, people appear to experience less stress and say that they are less dependent on nicotine."
"Behavioural change is by definition ambitious, especially when it comes to something as addictive as smoking."
Paul Kocken
Health scientist, Erasmus School of Social and Behavioural Sciences (ESSB)
With whom does ESSB cooperate?
KOCKEN: "The activities I outlined fall within the Grip and Health project. This in turn is part of the Healthy'R expertise centre, with which we aim to encourage vulnerable groups to make healthy choices: exercise more often, eat healthily and stop smoking. Healthy'R we started together with the municipality of Rotterdam in 2017, led by Prof. Semiha Denktaş. And of course, we also pull together within EUR, for example with the economic and medical sciences. We involve the entire social domain. Behavioural change is by definition ambitious, especially when it comes to something as addictive as smoking. But we are successful and will certainly continue for another four years. So no, I'm not sitting in a tower on campus Woudestein. It's the connection with partners in the city that makes my work so fascinating and useful."
How is the cooperation in the medical field?
BEEN: "It is very broad. A good example is the Taskforce Rookvrije Start (Smokefree Start). It brings together policymakers and healthcare professionals who are involved in pregnancy and early life. We were at the table of the dutch National Prevention Agreement of 2018, which includes a commitment to a smoke-free generation. As I said, we don't do this with a wagging finger. A pregnant woman knows herself that it is better to stop smoking. We help her with our expertise. At Erasmus MC we do research, financed from various health funds. As a result, we have conducted a study on effective tobacco policy abroad, among other things. In some countries it is forbidden to smoke in the car when there are children in it. The concentration of particulate matter in a car where people smoke is still eleven times higher than in a café. The legislation proved effective: the number of children exposed to tobacco smoke decreased by more than one third. As the Netherlands, we can learn from this. Furthermore, together with the municipality we are looking at how we can expand the number of smoke-free zones. There is now one on the Kop van Zuid. But we also work together within the university. With Professor Hans van Kippersluis we are looking into how we can encourage smokers to quit by means of a reward."
A smoke-free generation in 2035
BEEN: "That is so important. And I believe in it, public opinion is moving more and more in our direction. We are moving towards a society where smoking is less and less the norm. But again, I don't want to exclude smokers. Let's give them effective help."
KOCKEN: "It's not easy for people either, with all the stimuli that drive us to consume. That is why health psychology is an important subject. If we know how people deal with information, we can help the individual, but above all improve health on a population level."
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Dr Jasper Been is a paediatrician-neonatologist and associate professor of Perinatal Public Health at Erasmus MC. His scientific focus includes prevention in perinatology, preterm birth, as well as tobacco policy and smoking cessation during pregnancy. Been advised the government and the World Health Organization (WHO) on how to tackle smoking.
Dr. Paul Kocken is associate professor at the Erasmus School of Social and Behavioural Sciences. He has a broad scientific background with knowledge of public health, epidemiology, health psychology and health promotion. His specialisation is behavioural change. Kocken previously worked at the Municipal Health Service of Rotterdam and at TNO and is closely involved with the expertise centre Healthy'R.
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