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SRNT, Poster Session 1, abstract no. POS1-55 ; Background: The Hong Kong Government implemented a comprehensive smokefree legislation on 1 January 2007, which restricts smoking in indoor workplaces, restaurants, karaokes, public places/park, beaches, and school (both indoor and outdoor). This study aims to examine the perceived self-efficacy to quit smoking of smokers from two study samples after the smoke-free legislation. Method: Two cross-sectional samples were recruited. The first sample was Chinese youth smokers, aged 12-25, who called the Youth Quitline and received smoking cessation counseling. The second sample was Chinese smoking fathers living with non-smoking mother and a child aged ≤12 years old. We conducted a telephone survey in the two samples, consisted of 4 items on perceived impact of the legislation on self-efficacy to quit smoking and compared the proportions of smoking participants in the two studies by chi-square tests. Results: A total of 288 youth smokers and 608 smoking fathers completed the questionnaires. 75% of the youth smokers were male, 67% were students, a mean age of 17 years, and 62% had mild nicotine dependency. The smoking fathers' mean age was 39.3 years, 75.1% had secondary education, 95.4% were currently employed, and 62% had mild nicotine dependency. In both samples, about one-third had increased in their motivation to quit smoking (youths vs. fathers) (37% vs. 26%), perceived importance in successful quitting (32% vs. 25%), confidence in quitting (28% vs. 18%); and fewer had perceived difficulty in quitting (11% vs. 6%). While the majority (>60%) remained no change, significant differences were observed in all the 4 variables between the two samples after the legislation (p < 0.001). Conclusion: Although majority of the smoking fathers and youth smokers had little/no change after the legislation, more subjects reported an increase in motivation and confidence to quitting, suggesting the need for more effort from the government to promote smoking cessation. More youth smokers than smoking fathers showed positive changes indicating youth smokers are sensitive to the enactment of the legislation and changes in the overall environment, compared to adult smokers.

Conference Theme: Tobacco and Non-Communicable Diseases ; Poster Discussion 60. Making Smokefree the Norm in Challenging places: no. PD-1301-21 ; BACKGROUND: Implementation of comprehensive smoke-free legislation in Hong Kong banning smoking in most public places may not protect children from secondhand smoke (SHS) exposure at home. This study compared the cotinine levels of children in smoking households with and without SHS avoidance practices. DESIGN/METHODS: The data was collected from mothers and children recruited from 4 Maternal and Child Health … ; published_or_final_version

OBJECTIVE: Estimates of illicit cigarette consumption are limited and the data obtained from studies funded by the tobacco industry have a tendency to inflate them. This study aimed to validate an industry-funded estimate of 35.9% for Hong Kong using a framework taken from an industry-funded report, but with more transparent data sources. METHODS: Illicit cigarette consumption was estimated as the difference between total cigarette consumption and the sum of legal domestic sales and legal personal imports (duty-free consumption). Reliable data from government reports and scientifically valid routine sources were used to estimate the total cigarette consumption by Hong Kong smokers and legal domestic sales in Hong Kong. Consumption by visitors and legal duty-free consumption by Hong Kong passengers were estimated under three scenarios for the assumptions to examine the uncertainty around the estimate. A two-way sensitivity analysis was conducted using different levels of possible undeclared smoking and under-reporting of self-reported daily consumption. RESULTS: Illicit cigarette consumption was estimated to be about 8.2-15.4% of the total cigarette consumption in Hong Kong in 2012 with a midpoint estimate of 11.9%, as compared with the industry-funded estimate of 35.9% of cigarette consumption. The industry-funded estimate was inflated by 133-337% of the probable true value. Only with significant levels of under-reporting of daily cigarette consumption and undeclared smoking could we approximate the value reported in the industry-funded study. CONCLUSIONS: The industry-funded estimate inflates the likely levels of illicit cigarette consumption. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions. ; published_or_final_version

Parallel Session II: Prevention of Non-communicable Diseases ; Since the enforcement of the smokefree legislation in 2007, more smokers have been gathering near some public rubbish bins at outdoor bus stops, outside office buildings and shopping malls to smoke. These "hotspots" provided an opportunity of publicizing and providing smoking cessation services to a large number of smokers and motivate them to quit. We aimed to promote smoking cessation at smoking hotspots and evaluate the feasibility and effectiveness of a pilot outreach approach. Out of the 26 smoking hotspots near shopping malls and commercial buildings, 10 hotspots with the great number of smokers were selected for the intervention from February to August 2009. Trained smoking cessation counsellors disseminated 2-page promotional leaflets and proactively delivered brief smoking cessation counselling (less than 5 minutes for each smoker) to smokers for 4 hours at each hotspot. We evaluated the programme by counting of smokers non-smokers 1 week before and 1 week after the intervention. We observed the smokers' responses and behaviours when they were approached by the counsellors. In the observed 1,237 smokers at the 10 hotspots, the counsellors approached 751 (60.7%) smokers. 419 (55.8%) read or kept the promotional leaflets. 413 (55.0%) were willing to receive the brief on-site counselling. The intervention reduced the number of smokers at the hotspots by 7.8% (pre: 1,251, post: 1,154)) with 2.1% increase in non-smokers (pre: 5,004, post: 5,108). The proportion of smokers at hotspots reduced by 1.6% (95%CI 0.04%-3.1%, p=0.053) comparing 1 week before and after the intervention, whereas there was no significant difference in non-smokers (risk difference=1.6%, 95%CI -1.6%-4.7%, p=0.40). The outreach programme had a slightly positive impact to reduce the proportion of smokers at hotspots. The smoking hotpots are good locations for feasible and effective delivery of smoking cessation messages. Improvement in the approaching skills and incentives are needed. ; postprint

The World Congress of Cardiology: Scientific Sessions 2010. Beijing, China, 16-19 June, 2010 ; published_or_final_version

Study objective - To identify factors associated with smoking behaviour in primary school children in Hong Kong. Design - A cross sectional survey in which both children and parents completed questionnaires. The main outcome measure was the smoking status of the children; and risk factors (knowledge of and attitude to smoking and demographic and socioeconomic background) were identified as predictors of ever/never smoking. Setting and subjects - Altogether 9598 primary school children, aged 8-13 years, and attending 27 schools from two districts in Hong Kong participated. Main results - The prevalence of ever-smoking was 12% (1119)-15% (760) in boys and 7% (359) in girls. It ranged from 3% in 8 year old girls to 52% in 13 year old boys. The factors associated with ever-smoking included the following: being a boy (adjusted odds ratio 2.21; 95% confidence interval 1.89, 2.59), increasing age per year (1.48; 1.40, 1.57), living in Kwai Tsing district (1.29; 1.10, 1.50), having one or more smokers at home (2.07; 1.78, 2.39), and having a father who was not working (1.41; 1.19, 1.67). Children who were ever-smokers had both seen and approved of their friends) smoking (8.79; 5.33, 14.50), had a more positive attitude towards smoking (3.35; 2.21, 5.09), and were more successful in recognising cigarette brand names and logos (1.67; 1.42, 1.96), but they lacked confidence (1.78; 1.32, 2.39). Conclusions - The influences on child smoking are multifactorial and programmes in Hong Kong are failing to curb them. The control of these risk factors must be incorporated in the smoking prevention policy of Hong Kong and supported by future enforced legislation. ; published_or_final_version

Background: The Hong Kong government has proposed legislation for smoke-free policies in all restaurants and bars. This is opposed by certain sections of the catering industry. Objective: To assess public opinion on smoke-free restaurants and to estimate changes in patronage. Design: A population based, cross sectional random digit dialling telephone survey conducted from November 1999 to January 2000. Setting and participants: 1077 randomly selected subjects age 15 years or over (response fraction of 81.6%). Results: 68.9% (95% confidence interval (Cl) 66.2% to 71.7%) supported a totally smoke-free policy in restaurants. Experiences of discomfort or symptoms from second hand smoke in restaurants were common. The majority (77.2%, 95% Cl 74.7% to 79.7%) anticipated no change in their frequency of use of restaurants after a smoke-free policy. Increased use was predicted by 1 9.7% (95% Cl 17.3% to 22.1%) of respondents, whereas 3.2% [95% Cl 2.2% to 4.4%) stated that they would dine out less often. In multivariate analyses, non-smokers (adjusted odds ratio (OR) 4.9), people who ate three times or less per week in restaurants as compared to those who ate >10 times per week (OR 2.1), those who had previous experience of discomfort from exposure to passive smoking in restaurants (OR 2.8), or who had avoided restaurants in the past because of smoking (OR 1.9), were more likely to support a totally smoke-free policy in restaurants. Smoke-free policies do not appear to have an adverse effect on restaurants, and may increase business by a considerable margin. Conclusion: This comprehensive survey - the first in Asia - shows strong community support for smoke-free dining and predicts an overall increase in the patronage of restaurants after the introduction of legislation for totally smoke-free restaurants. ; published_or_final_version

Paper Session 15 - The Challenge of Second-Hand Smoke: PA15-3 ; BACKGROUND: After the Smoking Ordinance enacted in HK since 1/2007, shifting of smoking from outdoor to home was found, home becomes a major source of secondhand smoke (SHS) exposure of nonsmokers. OBJECTIVES: It aimed to assess the SHS exposure of babies and mothers living with smoking fathers of two housing types by using a biomarker. METHODS: Trios of smoking father, non-smoking mother and a baby under 18-months were recruited from Maternal and Child Health Centres (MCHCs) from 6/2008 to 10/2009. Consented couples completed the baseline survey including demographic data, fathers' household smoking behaviors and mothers' actions in protecting babies from household SHS exposure. Saliva samples from baby and mother were collected and then sent to the National University of Singapore for cotinine analyses. Log-transformations were used for the saliva cotinine due to skewed data. There were 2 housing types (public/private) and father was asked if they smoked at home (yes/no). MANOVA was used to compare the babies' and mothers' cotinine levels when fathers smoked at home under the 2 housing types. RESULTS: 1,158 trios were consented. 1,142 mothers' and 1,058 babies' samples were assayed. The mean age of the fathers and mothers was 35.5(±7.0) and 31.2(±4.9). The mean mothers' cotinine level was 12.15ng/ml (±61.20) while babies' was 2.38ng/ml (±6.01). 606 and 501 trios were living in public and private housing. Fathers' smoked at home led to higher mothers' and babies' saliva cotininary (mean log of mothers' cotininary: 0.14±0.62 vs. 0.05±0.55, p=0.06; babies: 0.16±0.38 vs. 0.07±0.34, p=0.003). Housing types influenced babies' cotinine level (public: 0.17±0.37; private: 0.10±0.36, p=0.01). MANOVA showed that fathers smoked at home (Λ=0.99, p=0.01) and housing types (Λ=0.99, p=0.01) were positively related to the saliva cotinine levels. CONCLUSIONS: Father smoked at home and the housing types have greater impact on babies' saliva cotininary, showing that they were highly exposed at home and in public housing environment. HK government should promote smoke-free homes and to provide more smoking cessation services to minimize the household SHS exposure to babies ; published_or_final_version

Background. Two-thirds of complaints received by the Hong Kong Environmental Protection Department in 1988 were related to poor air quality. In July 1990 legislation was implemented to reduce fuel sulphur levels. The objective of this study was to measure the impact of the intervention on respiratory health in primary school children. Methods. In all, 3521 children, mean age 9.51 years (SD = 0.78), from two districts with good and poor air quality respectively before intervention were followed yearly from 1989 to 1991. Children and parents reported the children's respiratory symptoms using self-completed questionnaires. Factor analysis was used to derive independent scores from 12 symptoms. Four groups of related symptoms were identified and binary variables (presence of any symptom in each group) were treated as dependent variables in modelling using generalized estimating equations procedures. Results. In 1989 and 1990 an excess of respiratory symptoms was observed in the polluted compared with unpolluted district. The significant effects (odds ratio [OR], 95% confidence interval [CI], P value) associated with living in the polluted district were: cough and sore throat (OR = 1.22, 95% CI: 1.04-1.43, P < 0.01) and wheezing (OR = 1.35, 95% CI: 1.10-1.66, P < 0.01). After the intervention, in the polluted district only, sulphur dioxide levels fell by up to 80% and sulphate concentrations in respirable particulates by 38%. Between 1989 and 1990-1991 there was a greater decline in the polluted compared with the unpolluted district for reported symptoms of cough or sore throat, phlegm, and wheezing. The risks to respiratory health for children exposed to tobacco smoke in the home were higher than those for air pollution in both 1989 and 1990 and remained unchanged in 1991. Conclusions. Air quality can be improved by fuel controls but an effective intersectoral approach is required if other risks from environmental tobacco smoke are to be avoided. ; published_or_final_version

Study objective - This study examined the impact on children's respiratory health of a government air quality intervention that restricted the sulphur content of fuels to 0.5% from July 1990 onwards. Design/setting/participants - This study examined the changes, one and two years after the introduction of the intervention, in airway hyperreactivity of non-asthmatic and non-wheezing, primary 4, 5, and 6, school children aged 9-12 years living in a polluted district compared with those in a less polluted district. Bronchial hyperreactivity (BHR) (a 20% decrease in FEV, provoked by a cumulative dose of histamine less than 7.8 μmol) and bronchial reactivity slope (BR slope) (percentage change in logarithmic scale in FEV, per unit dose of histamine) were used to estimate responses to a histamine challenge. The between districts differences after the intervention were studied to assess the effectiveness of the intervention. Main results - In cohorts, comparing measurements made before the intervention and one year afterwards, both BHR and BR slope declined from 29% to 16% (p = 0.026) and from 48 to 39 (p = 0.075) respectively in the polluted district; and from 21% to 10% (p = 0.001) and 42 to 36 (p > 0.100) in the less polluted district. Comparing measurements made in 1991 (one year after intervention) with those in 1992 (two years after intervention), only the polluted district showed a significant decline from 28% to 12% (p = 0.016) and from 46 to 35 (p = 0.014), for BHR and BR slope respectively, with a greater decline in both responses (p = 0.018 and 0.073) than in the less polluted district. Conclusion - Bronchial hyperresponsiveness tests can be used to support the evaluation of an air quality intervention. The demonstrated reduction in bronchial hyperresponsiveness is an indication of the effectiveness of the intervention. ; published_or_final_version

Background: Although the harms of smoking are well established, it is unclear how they extend into old age in the Chinese. Aim: To examine the relationship of smoking with all-cause and major cause-specific mortality in elderly Chinese men and women, respectively, in Hong Kong. Methods: Mortality by smoking status was examined in a prospective cohort study of 56 167 (18 749 men, 37 416 women) Chinese aged ≥65 years enrolled from 1998 to 2000 at all the 18 elderly health centres of the Hong Kong Government Department of Health. Results: After a mean follow-up of 4.1 years, 1848 male and 2035 female deaths occured among 54 214 subjects (96.5% successful follow-up). At baseline, more men than women were current smokers (20.3% vs 4.0%) and former smokers (40.8% vs 7.9%). The adjusted RRs (95% Cl) for all-cause mortality in former and current smokers, compared with never smokers, were 1.39 (1.23 to 1.56) and 1.75 (1.53 to 2.00) in men and 1.43 (1.25 to 1.64) and 1.38 (1.14 to 1.68) in women, respectively. For current smokers, the RRs (95% Cl) for all-cause mortality were 1.59 (1.39 to 1.82), 1.72 (1.48 to 2.00) and 1.84 (1.43 to 2.35) for daily consumption of 1-9, 10-20 and >21 cigarettes, respectively (p for trend <0.001). RRs (95% Cl) were 1.49 (1.30 to 1.72) and 2.20 (1.88 to 2.57) in former and current smokers for all deaths from cancer, and 1.24 (1.04 to 1.47) and 1.57 (1.28 to 1.94) for all cardiovascular deaths, respectively. Quitters had significantly lower risks of death than current smokers from all causes, lung cancer, all cancers, stroke and all cardiovascular diseases. Conclusions: In old age, smoking continues to be a major cause of death, and quitting is beneficial. Smoking cessation is urgently needed in rapidly ageing populations in the East. ; published_or_final_version

Background: Costs of tobacco-related disease can be useful evidence to support tobacco control. In Hong Kong we now have locally derived data on the risks of smoking, including passive smoking. Aim: To estimate the health-related costs of tobacco from both active and passive smoking. Methods: Using local data, we estimated active and passive smoking-attributable mortality, hospital admissions, outpatient, emergency and general practitioner visits for adults and children, use of nursing homes and domestic help, time lost from work due to illness and premature mortality in the productive years. Morbidity risk data were used where possible but otherwise estimates based on mortality risks were used. Utilisation was valued at unit costs or from survey data. Work time lost was valued at the median wage and an additional costing included a value of US$1.3 million for a life lost. Results: In the Hong Kong population of 6.5 million in 1998, the annual value of direct medical costs, long term care and productivity loss was US$532 million for active smoking and US$156 million for passive smoking; passive smoking accounted for 23% of the total costs. Adding the value of attributable lives lost brought the annual cost to US$9.4 billion. Conclusion: The health costs of tobacco use are high and represent a net loss to society. Passive smoking increases these costs by at least a quarter. This quantification of the costs of tobacco provides strong motivation for legislative action on smoke-free areas in the Asia Pacific Region and elsewhere. ; published_or_final_version

Background Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men. Methods In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes. Results Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97–2·24) and tripled risk among women (3·00, 2·71–3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35–59 years: 2·60, 2·30–2·94) than in older individuals (aged 70–89 years: 2·01, 1·85–2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35–59 years had the highest death RR across all age and sex groups (5·55, 4·15–7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35–59 years, the excess absolute risk was 0·05% (95% CI 0·03–0·07) per year in women compared with 0·08% (0·05–0·10) per year in men; the corresponding excess at ages 70–89 years was 1·08% (0·84–1·32) per year in women and 0·91% (0·77–1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes. Interpretation Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained. Funding UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).