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If you can read Dutch, you can visit my Dutch-language blog website at gezondheidwelzijn.wordpress.com.

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Last week, the SRNT Europe conference was held in Oslo which is about research on nicotine and tobacco. I really enjoyed and learned from the presentations and interactions at the conference and on Twitter. Here, I give a brief overview of my takeaways from the conference.

2019-09-12 09.04.07.jpgA large part of the conference was dedicated to e-cigarettes. Two keynote speakers (Lynne Dawkins and Robert West) focused on this topic and several of the sessions had this focus. Although the media were talking about the recent deaths that may have been caused by e-cigarettes, most of the speakers at the conference talked mainly about the benefits of e-cigarettes for people who want to quit smoking tobacco. Speakers at the conference worried about the lack of knowledge among the public about nicotine. Many people incorrectly believe that nicotine is the ingredient in tobacco that is causing most of the harms of smoking. This belief makes people assume that e-cigarettes are equally or more harmful than tobacco, which is not true and makes it less likely that people will benefit from the harm reduction potential of e-cigarettes. The other side of the coin was also highlighted in a meta-analysis on e-cigarettes as a possible gateway to smoking among youth. There was a strong association found between e-cigarette use among youth and later tobacco use, but conclusions about causality cannot be made.

NicotineAnother interesting theme at the conference was preference-based treatment for smoking cessation. Instead of only following evidence-based guidelines for the best aids and ways to quit smoking, we should also listen more to how people want to quit smoking themselves. If adherence to a certain treatment is low this might mean that we need better treatment rather than better adherence, said Peter Hajek. Although e-cigarettes are not that different from other nicotine replacement therapies, some people have a clear preference for one aid over the other. Also, some people may want to quit gradually by reducing the number of cigarettes they smoke per day instead of quitting abruptly. An updated Cochrane review presented at the conference showed that quitting abruptly does not result in superior quit rates than gradual quitting and thus both can be advised, depending on peoples’ preferences. How all this will work in practice remains the question, as preference-based treatment on top of evidence-based treatment asks more from health professionals.

SESThere were not a lot of sessions and only one keynote presentation (by Niamh Shortt) about inequalities in smoking. However, although it was not an important theme of the sessions, the topic did come up a lot during questions to speakers. Many conference delegates asked the presenters how their research relates to the group of smokers with a lower socioeconomic position. This is becoming the most relevant target group in many countries as smoking rates are mainly dropping among people with a higher socioeconomic position. For example, gradually reducing the number of cigarettes per day until you have quit smoking may be more feasible for people with a lower socioeconomic position (who are often more addicted to smoking) than abrupt quitting. In the keynote speech about inequalities, the importance of the environment was stressed and the potential of policies reducing the number of tobacco outlets for decreasing inequalities in smoking.

With the latest Tobacco Products Directive, all EU countries now have pictorial warning labels and many move to the implementation of plain packaging. The research presented at the conference covered these policies and several studies also went a step further by examining new possible packaging policies such as dissuasive cigarettes, efficacy labels (instead of health warning labels), or cigarette pack inserts. First results of studies about these new policies are promising and could be the way forward for a new European Tobacco Products Directive.

Finally, it was nice to see all the activity on the conference hashtag #SRNTE2019 on Twitter. More than 30 delegates were actively tweeting what they heard and learned at the conference. You can see a selection of those tweets below.

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Were you also present at the conference? Feel free to add your takeaways from the conference in the comments section below!

Since I started my research career twelve years ago, I have been combining two research jobs. Since the start, I have worked as a researcher at a university. Additionally, I have been a research & policy advisor at an expert centre for tobacco control, a research methodology teacher at a university of applied sciences, and currently Chief Science Officer of a research institute. I started with a combination of jobs because I wanted to work fulltime and couldn’t do that at the university at that time. Eventually, I got used to the nice variety of tasks, places, and people. Most of the time, I enjoy the combination of my two jobs, but at times it has also been stressful. These three things help me to keep enjoying the combination of two research jobs:

Seek synergy
Ideally your two research jobs together are more than the sum of its parts. In the past, I have worked on knowledge dissemination of the research themes and research projects that I did at my other job. Also, I have had students from one job work as internship on projects from the other job. And currently, I am doing research projects and writing research grant applications together with colleagues from both institutes where I work. It gives me positive energy when I know that there is an added value of having these two jobs.

Be flexible
When you have demanding research jobs with a lot of time pressure and deadlines, you need flexibility. If you have an important deadline for one of your jobs, maybe you can work fulltime on that for one or two weeks and catch up with your other job later that month. Or if you have a conference or a meeting on Thursday while your workday for that job is on Wednesday, you can change your workdays for that week. If your employer or the type of work does not allow you any flexibility, combining this job with another demanding job may be difficult.

Be where you are
Having two research jobs can be stressful, especially when deadlines or other pressures from both jobs keep fighting for attention in your head. If I need the flexibility, I have workdays with meetings for both jobs or when I answer emails from both jobs. But if its not needed, I like to keep my two jobs at separate days. On those days, I try to really ‘be where I am’ and not think about all the things I need to do at my other job. This ‘mindfulness’ can be practiced and helps to keep the stress away.

how-to-handle-working-two-jobs

If you have any other thoughts on how to handle two research jobs, leave them below in the comments section.

Six months ago, I published a blog about how to be the best PhD supervisor you can be. Although this blog was about good PhD supervision practices, I got quite a few responses on that blog about bad PhD supervision practices and how it affected the PhD students who had to deal with that. Through these responses, I discovered that bad PhD supervision practices come in different forms and all seem to have negative effects on PhD students.

abusive-boss

I read several recent scientific papers on this subject and came up with four different types of bad PhD supervision practices:

 

1) Abusive supervision

A PhD supervisor with an abusive supervision style may respond in a rude way, may humiliate people, blame other people for their own mistakes, and/or break promises. This may sound extreme, but it is something that has been reported in several studies. It can be illustrated with a quote from a qualitative study from Finland1: “The supervisor first used a significant part of the seminar yelling at me about how I cannot make decisions about the seminar, that it’s none of my business, that it’s against all principles, that something terrible has now happened, and what do I think I’m doing with my priorities anyway. (…) Then another senior researcher said – and I will always remember this – that my research is trivial, that what I had prepared for my presentation was nothing.” As can be expected, a quantitative study showed that abusive supervision is associated with more anxiety, less psychological well-being, and lower self-esteem among students2.

 

2) Controlling supervision

PhD students with a controlling supervisor report that they are not allowed to make any research choices on their own1,3. They cannot chose their own topic for their next paper, the methodology or theoretical perspective that they will use, or how they manage their project. This is either because they are told explicitly that they are not allowed to make their own choices, because they are told what to do without opportunity for negotiation, or because their own ideas are torpedoed until the supervisors’ ways are ‘chosen’ by the PhD student. One PhD student explained: “It would be great to be able to truly have a discussion with my supervisor. But it isn’t like that. My supervisor will say: No, no, no, that is not how it goes!1. A large risk of controlling supervision is that it can lower intrinsic motivation and creativity of PhD students4.

 

3) Passive supervision

A supervision style that may be seen as the opposite of controlling supervision is passive supervision. Supervision may not even be the appropriate term here, because it is characterized by an absence of leadership and avoidance of intervention5. A passive supervisor doesn’t like to make decisions and only intervenes when serious or chronic problems occur. They just let the PhD students do their research and only respond to specific questions without raising issues themselves. Sometimes, passive supervision is not a trait of the supervisor, but a phase in which the supervisor loses interest in the project of the particular student. As one PhD student put it: “Students change and projects change, and supervisors lose interest and move on to new projects in which they have doctoral students, and you are left hanging out there on your own1. Passive supervision may also occur because of time constraints: when supervisors have too many PhD students or are too busy with other tasks1,6. Passive supervision is associated with more psychological distress among PhD students7.

 

4) Apathetic supervision

A PhD supervisor with an apathetic supervision style lacks commitment or passion for the supervision, the research, and/or the student. This type of supervisor may use ‘short-cuts’ in research or may not be interested in following the latest developments in the research discipline8. An apathetic supervisor may also not really care about PhD students’ well-being as long as the research work is done1. A real risk of apathetic supervision is that PhD students become apathetic as well. A PhD student interviewed for a qualitative study performed in the United States described that “The department became cold, calculating, and lost that humanity9. Students who were once committed and enthusiastic can become frustrated and discouraged8.

 

The four types that I described above are probably not a full typology of bad PhD supervision practices, but these four types stood out in the literature that I read about bad PhD supervision. Also, I recognized the types from the experiences of PhD students that responded to my previous blog. Hopefully, this blog provides some insight for PhD students who have to deal with bad PhD supervision practices. I don’t have the illusion that supervisors with extremely bad supervision practices read this blog; and if they do read this blog they will probably not change their practices. However, every PhD supervisor may have their own negative tendencies (e.g. being a bit too controlling or a bit too passive) and my hope is that these supervisors are encouraged by this blog to think about how they can improve their supervision.

I would like to hear what you think about this blog and whether you have any other experiences or suggestions. Please respond in the comments section below, on twitter, or send me a message.

 

References:
1. Löfström, E. & Pyhältö (2014). Ethical issues in doctoral supervision: The perspectives of PhD students in the natural and behavioral sciences. Ethics & Behavior, 24, 195-214.
2. Hobman, E. V., Restubog, S. L. D., Bordia, P., & Tang, R. L. (2009). Abusive supervision in advising relationships: Investigating the role of social support. Applied Psychology: An International Review, 58, 233-256.
3. Gunnarsson, R., Jonasson, G., & Billhult, A. (2013). The experience of disagreement between students and supervisors in PhD education: A qualitative study. BMC Medical Education, 13, 134.
4. Oldham, G. R., & Cummings, A. (1996). Employee creativity: Personal and contextual factors at work. Academy of Management Journal, 39, 607-634.
5. De Hoogh, A. H., Den Hartog, D. N., & Koopman, P. L. (2004). De ontwikkeling van de CLIO: Een vragenlijst voor charismatisch leiderschap in organisaties. Gedrag en Organisatie, 17, 254-281.
6. Bazrafkan, L., Shokrpour, N., Yousefi, A., & Yamani, N. (2016). Management of stress and anxiety among PhD students during thesis writing: A qualitative study. The Health Care Manager, 35, 231-240.
7. Levecque, K., Anseel, F., De Beuckelaer, A., Van der Heyden, J., & Gisle, L. (2017). Work organization and mental health problems in PhD students. Research Policy, 46, 868-879.
8. Aasheim, L. (2011). Practical clinical supervision for counselors: An experiential guide. New York: Springer Publishing Company.
9. Jairam, D. & Kahl, D. H. (2012). Navigating the doctoral experience: The role of social support in successful degree completion. International Journal of Doctoral Studies, 7, 311-329.

Dear Dr.

Greetings for the day!!!

Are you also annoyed by the numerous academic spam emails you receive “cordially inviting you to publish your eminent research (a book, follow-up research article, or mini-review)”, asking you to join the editorial board of some obscure open access journal, or welcoming your “gracious presence” at a conference that is not related to your research field? You are not alone.

No spam

What to do about this annoying academic spam? Andrew Grey and colleagues published an intervention study in BMJ’s 2016 Christmas edition examining whether unsubscribing from the sender’s distribution lists led to fewer spam messages. Unsubscribing reduced the frequency of spam messages at first, but hardly changed the frequency on the long term, thus not being worth the effort. The authors concluded that “academic spam is common, repetitive, often irrelevant, and difficult to avoid or prevent.”

Luckily, I have devised the solution to this problem and am happy to share this with the academic research community. I have created a spam filter that works for more than 90% of the academic spam I receive and it rarely identifies a ‘normal email’ as spam. In the past 14 days, I received 57 academic spam emails of which 53 ended up in my spam folder due to my customized spam filter. Below you can see which phrases are in my spam filter. If you want to use an academic spam filter too, you may want to tweak the phrases for the specific spam messages that you receive yourself.

Part 1: Phrases to filter out most of the spam messages about submission requests and editorial board invitations:
articles are invited
come across your recent article
contribute a manuscript
contribute any kind of article
contribute their research
contribute your research
cordially invited
cordially invite you
cordially welcome you
either a research article or a review
eminent
excellent scholar as you
followup research article
follow-up research article
glance at your previous
glance at your published
gone through your profile
greetings!!
greeting for the day
greetings for the day
greetings of the day
humbly request you
illustrious people like you
immense pleasure to invite you
in search of qualified researchers
in the upcoming issue
inaugural issue
invite you to contribute an article
invite you to publish with us
inviting you to publish your research
is a peer-reviewed open-access journal
is a peer reviewed open access journal
is an international peer-reviewed open-access journal
is an international peer reviewed open access journal
join as editorial board member
join the editorial board
join us as an author
join us as author
look at your previous article
mini review
mini-review
minireview
now accepting research papers
now accepting submissions
our journal accepts articles
part of our editorial board
precious paper
prepare an article on a different topic
preparing an article to submit
prominent people like you
publish books
publishing a followup
publishing a follow-up
publishing enquiry
publishing in our upcoming issue
request for manuscripts
request for submission
serve the journal as editorial board member
submission request
submissions for upcoming
submit a short review
submit an article
submit your manuscript
submit your research
value your outstanding contribution
we accept original research
we have gone through your recent publication
we invite and publish original research
welcome to submit short
welcome your manuscript
with reference to your article
your gracious presence
your impressive scientific publication
your valuable article
your valuable contribution
your valuable research

Part 2: Phrases for reminder spam messages*:
have not heard back from you
not received any response from you
not yet received any response from you
we contacted you earlier but
we did not get your response
* don’t use these phrases if you don’t respond to other types of emails and do want reminder messages for that!

Part 3: Phrases for specific fields and conferences you are not interested in. These should be customized to the fields and conferences you receive spam messages about. For me they are:
anesthesia
antibodies
archeology
biotech
conference on cancer
congress on cancer
dermatology
diabetology
economic and business
engineering
food technology
immunology
medical research archives
medicine conference
mitochondria
nanosuspensions
nephrology
nursing
orthopaedic
pediatric
pharmacy
pharmscience
reagency
reagents
statin therapy
stevia
TB-HIV

How it works? You just create a rule in your email program (find out the technical details here) and make sure that if the above (or customized) phrases are in an email they are automatically moved to your spam folder. You might want to check this folder now and then to make sure that it does not contain email that is of interest to you.

Are you going to use this life hack for researchers? Or do you have other solutions to the problem of academic spam? Feel free to share your experiences in the comments below.

Where I come from, PhD supervision is often done in a team with one or two professors together with a post-doctoral researcher or assistant professor who is the ‘daily supervisor’ (or co-promotor) of the PhD student. There is no manual for this daily PhD supervision task and there are few courses that tell you what you should and what you shouldn’t do. Often, PhD supervisors just do the things that they appreciated from their own PhD supervisor and try to do other things differently. However, sometimes it becomes a bit of a trial-and-error process which is not always good for the PhD student.

I started as a PhD supervisor four years ago. My first PhD student is now graduated and I am currently supervising five others. I learned a lot from these experiences, but of course I am still a relative beginner with this. Then why did I wrote a blog with such a pretentious title? First of all, it was just meant to attract your attention and make sure you clicked on the link to this blog (so far, I succeeded). Second, I think it is important that we try to be the best PhD supervisor we can be. Lately, there is a lot of media coverage on rising stress levels and mental health problems among PhD students and I also see this happening around me. This makes me worried and I think that making an effort as PhD supervisors is the most important thing we can do. Five other things that I learned in the past four years can be read below.

1. Be available, open, and reliable
To start simple, my first tip is to be available, open, and reliable. This means answering PhD students’ emails (within reasonable time) and making time for regular meetings, but it also means creating an environment in which they feel save to be open and to ask you anything that they worry about. Be honest if you don’t know the answer to one of their questions and help them with finding an answer elsewhere. Be vulnerable and do sometimes talk with them about your own struggles too.

2. Learn, evaluate, and adapt
If there is a course on PhD supervision available, I would suggest to take it. I took a two-day course when I just started as a PhD supervisor and am happy I did that. You can also learn from other PhD supervisors by talking with them about how they approach things. However, the most important person that you can learn from is your PhD student. I think it is important to realize that the same approach does not work for everyone. So evaluate with your PhD students about what they think about your supervision and adapt your style accordingly. This may sound like you should do everything that your PhD students want you to do, which is obviously not the case (e.g. you do not want to write their thesis for them). But the way in which you do things can sometimes make a big difference.

3. Ask about daily worries and activities
Probably more than half of the time that I spend with my PhD students is not spend discussing the content of their PhD research. I try to focus more on their daily worries and activities and on teaching them skills instead of knowledge. Ask them how they are doing, what they are doing, and what they need help with. Not all PhD students will tell you if something is up, so try to observe too. The look on someone’s face when they walk into your door often reveals a lot. Don’t be scared to tell them what you see and ask what’s going on. Of course, you can be wrong too. I once thought that something was terribly wrong with a PhD student when he walked into my office, but it turned out that he just thought it was very cold in my office…

4. Let them make their own choices
In my opinion, a PhD thesis should really be a product of the PhD student and not of the supervisors. Therefore, I think it is important to let PhD students make their own choices in their research and writing. If they ask for advice on the content of their PhD research, ask them what they think first (I know this is annoying, but important nonetheless). Then explain their options and the consequences of different choices, but do not make the choices for them. This is not always possible when one of the choices is clearly the best choice, but try to let them draw that conclusion themselves.

5. Watch out for warning signs
No matter how good of a PhD supervisor you are, you cannot always prevent a burnout or other mental health problems from occurring. PhD students who are perfectionists and are very tough for themselves, are likely to go through something like that one day. Even though you cannot always prevent it, it is important to watch out for warning signs (like tiredness, health problems, working through the weekends, panic, and frustration). Tell them if you are worried about their mental health and be supportive. Have you experienced something like this yourself? Then open up and talk about how you’ve coped and what you’ve learned from this. Explain to them that it is important to switch off from work during evenings, weekends, and vacations.

PhD supervision

Hopefully this blog inspired you to be the best PhD supervisor you can be. I am curious to hear whether you’ve learned something from this blog and whether you have any other advice about PhD supervision. Please respond below in the comments section or send me a message on Twitter.

Earlier this week, the World Conference on Tobacco or Health (WCToH) was held in Capetown, South Africa. It was a conference with long twelve-hour days filled with inspiring presentations. It was great to reconnect with researchers and advocates around the world, to see some of them in person for the first time after having worked with them through email and skype, and to make some new connections. There were many parallel sessions at the conference, so this conference report reflects only the part of the sessions that I could attend.20180307_092545

One of the things that I like about the WCToH conferences, besides the science, is hearing about the experiences, strategies, and aspirations of researchers and advocates around the world. That’s why I attended several sessions that dealt with tobacco endgames. Tobacco endgames are strategies to end tobacco use in the population or at least bring it back to negligible proportions. There are many different possible strategies that can be used and there is no agreement about the best strategy. For example, some countries choose to make use of reduced-harm products (such as e-cigarettes and potentially heat-not-burn tobacco) to achieve the endgame of a tobacco-free country, while other countries want to have a nicotine-free country. What the different endgame strategies presented at the conference do seem to have in common are that increasing tobacco taxes is at the core of the strategies to reduce tobacco use in the population, while at the same time making sure that population groups in which smoking rates are higher get the support they need to be able to quit. Endgames are a relatively new concept in tobacco control and the first conference that I heard about them was the ECToH conference in Amsterdam in 2011, while the SRNT conference in Boston in 2013 was the first conference that I attended that really started to focus on endgames. In comparison with previous conferences, it is clear that the strategies are becoming more detailed and better underpinned with research, such as simulation studies. An example is the presentation by Dr. Michael Chaiton who’s analyses of Canadian data not only predict a drop in tobacco use prevalence, but also a drop in the number of cigarettes people smoke per day, making the smokers’ population less and less dependent. Presentations by Deborah Arnott from the UK and Kylie Lindorff from Australia made clear that a tobacco-free generation could be near in these countries, where smoking rates among youth have dropped to 5%.

WCToH2018 ecigarettes and youthI also attended a few sessions about electronic cigarette use among youth, which were very interesting sessions in which high-quality research was presented. Dr. Cathy Backinger presented an overview of several longitudinal studies that have now shown that youth who start with using e-cigarettes are more likely to start using tobacco later on. There is no consensus about what this actually means. It could mean that e-cigarette use is a gateway to tobacco smoking (the catalyst hypothesis), but this is not necessarily the case. It could also mean that youth who experiment with one product are more likely to experiment with another product (the common liability hypothesis). It does not seem feasible to establish with research which explanation is right. This would require an experimental design in which children are randomized to start with e-cigarettes, which would be unethical. We can, however, examine population trends. In the UK and the US, e-cigarette use among youth is rising while tobacco use among youth is declining. Prof. Ron Borland made the point that this makes the catalyst or gateway hypothesis unlikely or at least the effect could not be very large. Another possibility is the diversion hypothesis, which states that e-cigarette use could have a preventive effect among youth because some youth may use these products instead of using tobacco. Although this hypothesis was posed during the discussion, no evidence was presented that this may be the case. Therefore, many presenters agreed that whether or not e-cigarettes are a gateway to tobacco use, it is undesirable that young non-smokers use these products that do contain harmful ingredients.

Many other important and interesting themes were discussed during the conference. For example, how to reduce tobacco use among vulnerable populations such as lower educated people, homeless people, street children, and elderly. Recent tactics of the tobacco industry were discussed, such as bribery of ministers and journalists and the tobacco-industry funded ‘Foundation for a Smokefree World’. International Women’s Day was celebrated with a speech by the first black female president of the conference, Dr. Flavia Senkugube, and keynote presentations by Dr. Judith Mackay, Dr. Lorraine Greaves, Dr. Matshidiso Moeti, and Malebona Precious Matsoso.

WCToH2018 symposium early career

My own contribution to the conference was a poster about the long road to smokefree bars in the Netherlands and a symposium for early career researchers. In the symposium, I presented about writing academic papers, grant proposals, and blog posts. In this same symposium, Prof. Ruth Malone (chief-editor of the scientific journal Tobacco Control) presented about publishing academic papers. Dr. Ute Mons presented about public health advocacy, in which the main message was to be proactive, persistent and passionate about the dissemination of your research. Dr. Becky Freeman presented about the professional use of social media. She argued that it is important to consider your digital footprint when you are a researcher (so set up a Google Scholar account and join the Twitter conversation).

 

It has been an amazing conference and it was a great experience that it was held in Cape Town, which was a first for the WCToH conference to be held on the African continent. The next WCToH conference will be held in Dublin, Ireland, in March 2021. I am already looking forward to it!

In 2017, we performed a study to determine which preconditions and success factors should be taken into account when developing lifestyle interventions for people with a low socioeconomic status (SES). With preconditions and success factors we do not mean the behavior change methods themselves, but everything else you need to consider to make sure that people actually use your intervention. Because it is very difficult to investigate empirically which preconditions are most important (you would need an experiment with many conditions), we asked experts to reach consensus about this topic. We only asked experts from the Netherlands, because we thought that the answers may be culture-specific and because we wanted to use the results directly for the development of our own local lifestyle intervention. The academic paper about this study was published in a Dutch-language journal, but I got permission from the journal to share the results in English on my blog.

Poppetjes met tandwielenHow we did it
To come up with a list of Dutch experts in lifestyle change among people with a low SES, we performed a search in PubMed. Our search strategy contained MESH terms for socioeconomic status, smoking, physical activity, nutrition, and alcohol, and a search term for the Netherlands. Experts were included if they published at least five papers on these topics in the last five years. This resulted in a list of 54 experts who were invited to take part in the study. Three experts were added because they were spontaneously mentioned by other experts on the list. We performed a three-round Delphi study, which is a method to reach consensus using questionnaires. In the first round, 28 of the experts participated and they gave open answers on the question what important preconditions are for lifestyle interventions for people with a low SES. These open answers were summarized in categories and presented to the experts in the second round. In the second round, all 28 participated again and they were asked to rate all preconditions on a scale from 1 (very unimportant) to 7 (very important). In the third round, 26 of the experts participated. Experts were only presented the preconditions on which no consensus was reached during the second round and they were shown the answers from the rest of the experts during the second round before they were asked to give their rating again. In line with previous research, we decided that an interquartile deviation (IQD) of 1 or lower was seen as consensus and that a median of 6 or higher was seen as an important precondition.

What we found
In the first round, 196 open answers were given, which could be summarized in 36 categories. The most mentioned preconditions during the first round were that intervention developers should take the daily worries and domestic situation of the participants into account and that they should keep the price of participation very low or make it free. During the second and third round combined, the experts reached consensus about the importance of 22 of the 36 mentioned preconditions for a lifestyle intervention for people with a low SES. Of the 22 preconditions on which consensus was reached, 17 were rated as important. A summary of those 17 preconditions can be seen in Table 1. Interventions should be well prepared, accessible, should use easy materials, and have a large and sustainable reach. Table 2 gives all results that were obtained during the three questionnaire rounds.

Table 1: Summary of the 17 preconditions on which consensus was reached that they are important.

Table 1 TSG

Table 2: All results of the Delphi rounds 1, 2, and 3.
Table 2 TSG

What this means
The results of our study were not very surprising and very much in line with the literature, but that is of course a good sign and a logical consequence of asking experts who regularly publish on this topic what they know. What I thought was interesting, is that experts did not reach consensus about the importance of a theoretical basis for the development of an intervention. It seemed that the experts thought it is more important to listen to the target group and involve them in the development than to use theoretical insights. Another interesting result is that ten of the 28 experts mentioned during the first round that it is a good idea to work with (financial) incentives for participation or for successes. It was the third most mentioned precondition. Despite that, consensus was not reached about the importance of this precondition, implying that more research is needed on the differential effectiveness of incentives for people with a low SES (which was also concluded in a recent meta-analysis).

Some limitations
Even though this is a blog and not an academic paper, I feel compelled to point out a few limitations of our study. First, only half of the invited experts participated in our study. Second, only experts were invited who published at least five academic papers in the last five years. Therefore, only scientists could participate and we don’t know whether the same preconditions are considered important among other groups. Finally, it is possible that (some) experts have given socially desirable responses instead of their real opinion. An indication is that all preconditions scored a median of 4 on a scale from 1 (very unimportant) to 7 (very important), even though there were preconditions in the list that contradicted each other.

What we can conclude
The results of this study give some important directions for which preconditions are most important in the development of lifestyle interventions for target groups with a low SES. The 17 most important preconditions on which consensus was reached are summarized in Table 1. In short: interventions should be well prepared, accessible, should use easy materials, and have a large and sustainable reach. Future research should repeat this type of analysis in other countries and among other target groups and should also collect qualitative data to get more insight into why and how these preconditions are important, for example by performing qualitative in-depth interviews.

Where you can find more information (in Dutch)
Nagelhout, G. E., Verhagen, D., Loos, V., & De Vries, H. (2018). Belangrijke randvoorwaarden bij de ontwikkeling van leefstijlinterventies voor mensen met een lage sociaaleconomische status: Een Delphi-onderzoek. Tijdschrift voor Gezondheidswetenschappen, 96, 37-45.

Yesterday, the FADO conference on drug addiction was held in Utrecht, the Netherlands. The day started with a keynote speech by Prof. Anneke Goudriaan who showed us that current treatments for drug addiction have only moderate effects. However, she explained that neuroscience will result in improved treatment in the coming years. Other presentations also showed promising research developments to improve addiction treatment.

Dr. Peter Blanken talked in his keynote speech about the new treatment guideline for addiction to non-opioid drugs. This guideline contains too many elements and recommendations to address in this blog, but two elements stood out. The first was that the guideline is based on a recovery model instead of a clinical model of addiction. The second was that Dr. Blanken strongly recommended to implement contingency management for substance use on a large scale in specialist addiction care. In contingency management, substance use abstinence is rewarded in cash, with vouchers, or with a lottery.

Many new studies and approaches were presented at the FADO conference. Several of these new approaches were based on the recovery model that Dr. Blanken also talked about. For example, the new project ‘Recovery Pathways’ that Thomas Martinelli and Lore Bellaert presented. Many presenters also stressed the importance of involving the social network of drug users and improving quality of life. Dr. Eric Blaauw even called this a necessary paradigm shift. Although many of the presented studies only examined one approach (such as e-health or a pharmacological treatment), -when asked- all presenters recommended to combine different types of treatment. For example, Dr. Matthijs Blankers explained that there is evidence that e-health is more effective when combined with behavioral support.

A large part of the conference was devoted to vulnerable populations, such as youth, people with psychiatric comorbidity, mild intellectual disability, a low socio-economic status, and men who have sex with men. Many of this research was work in progress, so we will have to wait until we know how to help these groups.

Finally, a collaborative called ‘Verslavingskunde Nederland’ was presented at the conference, which is a collaboration between several Dutch addiction institutes. One of their first projects is to prioritize important research topics in addiction science in the Netherlands. This project is carried out by IVO, NISPA, and Zwarte Gat. All scientists, health professionals, administrators, policy makers, funders, and clients from the Netherlands with ample experience in addiction research or practice are invited to help with prioritizing research topics by participating in a survey study. More information about the study and how to sign up can be found here. The project will result in a research agenda for addiction science in the Netherlands. Hopefully, prioritized research questions will be answered at future FADO conferences.

Last but not least, an impression of the FADO conference on Twitter [in Dutch]:

#FADO2017

Within two weeks time, my first PhD student – Karin Hummel – will defend her PhD thesis. I remember very well how proud I was when her first academic paper was published. Now, she has published several papers and has written a very interesting and high-quality thesis. I am sure she will do a great job defending this to the thesis committee on Wednesday 13 September. In this blog, an outline of the main findings from her PhD thesis is given. You can access her PhD thesis here.

Cover thesis Karin Hummel

Karin’s PhD research had three main aims. The first aim was to evaluate the impact of inconsistent tobacco control policy implementation processes. The second aim was to investigate subgroup differences according to socioeconomic status (SES) in these evaluations. Finally, the third aim was to assess the validity of different instruments to measure quit intention. The policies that were the subject of this thesis were the legislation of electronic cigarettes (e-cigarettes), smoking restrictions in public places, reimbursement of smoking cessation support, cigarette prices, and warning labels on cigarette packs. In particular, the focus in these evaluations was on legislation that substantially changed after implementation and, in some cases, was even temporarily reversed.

In the first part of her PhD thesis, Karin examined tobacco control policies in the Netherlands that were inconsistently implemented. This included legislation about e-cigarettes, smoking restrictions in bars, and reimbursement of smoking cessation support. When legislation about e-cigarettes in the Netherlands included an advertisement ban, awareness and use of e-cigarettes decreased (chapter 2, paper published in International Journal of Drug Policy). Whereas both increased in periods when advertisements were allowed. Social acceptance of smoking in bars decreased, even though the rules about smoking in bars kept changing (chapter 3, paper published in Nicotine & Tobacco Research). Awareness of reimbursement possibilities of smoking cessation support increased after the implementation and decreased again when the legislation was reversed (chapter 4, paper published in Drug and Alcohol Dependence). Awareness of the media campaign that accompanied the implementation of the reimbursement was related to more quit attempts, implying that the campaign increased the impact of the reimbursement.

The second part of her PhD thesis was on socioeconomic differences. People with a low socioeconomic status (low education and/or income) are known to be more likely to smoke, to be more addicted to tobacco, and to have more trouble with quitting. Notable was that people in the Netherlands with low levels of income and education were more likely to accept smoking in public places and less likely to implement home smoking bans (chapter 3, paper published in Nicotine & Tobacco Research). Another study showed that European smokers with a low socioeconomic status were more likely to report that tobacco control policies triggered them to think about quitting (chapter 5, paper published in Drug and Alcohol Dependence). Income differences were especially large for the price of cigarettes and free or lower cost medication as trigger to think about quitting.

In the third part of her PhD thesis, Karin assessed the validity of different instruments to measure intention to quit smoking. An external validation of the Motivation to Stop Scale showed that this scale predicted attempts to quit smoking in the next year (chapter 6, paper published in European Journal of Public Health). In a final study, three quit intention measures were compared: the Motivation to Stop Scale, an assessment of the Stages of Change, and a Likert Scale (chapter 7, paper published in Nicotine & Tobacco Research). Results implied that the three instruments had a reasonable and comparable validity, but that the Likert scale performed slightly better under the studied conditions.

Implications of this PhD research for tobacco control policy, are that:
• Smoking restrictions in public places should be strengthened and could be expanded to new places in the Netherlands, for example banning smoking in cars with children.
• Educational campaigns about the harms of secondhand smoke tailored to low SES smokers are needed.
• Reimbursement of smoking cessation support should be continued and complemented with regular media campaigns.
• Tobacco taxes should regularly and substantially be increased, because this is the most promising tobacco control intervention, which may also help to reduce socioeconomic inequalities in smoking.

Mind if I smoke

Last week I read the bookScarcity: Why having too little means so much’, written by economist Sendhil Mullainathan and psychologist Eldar Shafir. It is not a new book, it was published in 2013, but I didn’t found time to read it before. The book explains why. I experienced scarcity of time, which caused tunnel vision and I focused only on urgent tasks (things that needed to be done immediately) and not on important things that are not urgent (like reading good books). It is a really interesting book and I recommend making time to read it.

The book deals with different types of scarcity, like scarcity of money, time, calories, and social contacts. Scarcity is seen as having less than you feel you need. The authors argue that scarcity takes control of your thinking, creates tunnel vision, short-term thinking, and decreased ‘bandwidth’. Although they acknowledge that being poor (having scarcity of money) is much worse and less of a free choice than having too little time, showing the commonalities between the two situations is very useful. The authors try to make the reader that has experience with having too little time more empathetic for people who have too little money. They argue that poor people do not make bad decisions (like taking expensive loans) because of their personality or a lack of skills, but because scarcity takes control of their thinking. The authors substantiate this with several experimental studies in which people are randomized to get a scarcity manipulation or not. People who are manipulated into having scarcity are tested as having lower intelligence and executive control. Therefore, the authors claim that it is not the case that poor people are less intelligent or have less self-control. All people, if they were poor, would have less effective bandwidth.

Most things in the book are really well explained with many clear examples, which makes the book an easy read. One thing that kept bothering me a bit while reading the book was whether scarcity is really something different than psychological distress. The authors do go into this, but dismiss this idea after less than two pages of explanation. They do acknowledge that scarcity leads to stress, but say that stress does not negatively affect people’s cognitive capacities and executive control. By only focusing on stress we would miss deeper connections and get limited insights in the thinking pattern of scarcity. Although I’m not sure whether it really matters and the authors are probably right anyway, they do not really convince with this explanation.

The book has relevance for poverty reduction, time management, health promotion, and other areas. In one of my current projects, I am working on a health promotion intervention for low-income multi-problem families who receive intensive family home care from specialized social workers. In terms of Mullainathan and Shafir these families experience scarcity of money and have very little bandwidth which creates other problems (in my own terms before reading the book: these families have extreme psychological distress due to all of their problems). The social workers have scarcity too: they have little time. Our health promotion intervention is seen as important among both the families and the social workers, but not urgent. Health promotion is not ‘inside the tunnel’, because fixing the money problems, housing instability, and ensuring safety of the family are more urgent. Of course our health promotion program may make people feel better by making them more physically active, relieving stress, and getting more social contacts. But one thing that health promotors often do not realize and that is explained in the book is that there is also a cost: people with scarcity have limited bandwidth and if they spend it on health promotion (e.g. trying to eat more healthily), they cannot spend it on their other problems.
The authors of the book give a few helpful pointers for health promotion programs. They recommend being forgiving instead of ‘getting tough’. If people don’t show up (which is probably caused by their reduced bandwidth), they should still be able to follow the program. They should also get reminders to come to the program. If a course can be shorter and simpler, it should be, because it will be more effective and leaves bandwidth for other things. The program should keep in mind when people have most bandwidth, e.g. information sessions for poor people should not be held in weeks when people are short on money (before they receive their unemployment assistance or salary). People should also get help with filling in forms -even if they are capable of doing this themselves-, because they may otherwise forget or delay doing it, because they have more urgent things to think about. We should keep in mind that social workers and other professionals have scarcity too and that we may also want to adjust their role in the program to the fact that they have reduced bandwidth.

Have you read the book too and have any thoughts on the concept of scarcity or the applicability to one of your own projects? Happy to hear about it in the comments below!

When I Twitter_60830064_illustrationstarted using Twitter five years ago I had a simple goal in mind. I wanted to organize a symposium and I wanted relevant people to be there. So I started collecting followers first and then used my account to advertise my symposium. This strategy worked well for me and later on I also found many other ways in which Twitter can be useful and add value to my work as public health researcher. However, I often get surprised reactions from researchers who do not use Twitter that I am “wasting my time” with that. Of course Twitter can be a waste of time for people who get distracted on Twitter easily and keep reading and clicking until they realize that several hours have past. Here is a three step approach for using Twitter as a researcher without wasting your time.

 

Note that this is not a guide for how to use Twitter. Twitter is intuitive, so you can probably figure this out yourself. If not, there are guides available on how to set up an account, how to get followers, how to use hashtags, twitter terminology, and many more.

 

Step 1: Deciding whether you want to use Twitter (10 minutes)

  • Think about pros and cons of using Twitter for your specific situation. If you are a newbie to using Twitter as a researcher then start with reading a blog about this (for example this one). Pros can be that you can follow interesting news and publications in your research field, that you can advertise your publications, call for papers, blogs, or job adverts, that you can easily connect with researcher whom you don’t (yet) know personally, and that you can ask questions and get quick answers. A possible con of using Twitter is that it takes time; it doesn’t have to be much time (as you can read below) and the pros can outweigh this con, but Twitter does take some time. Are you the type of person who would get lost in a Twitter feed during office hours while losing track of time? Then starting Twitter while you also have a very busy work schedule is probably not very smart and you can stop reading this post.
  • If you think there could be more pros than cons for your specific situation, then take a look at twitter.com. Hit the search button and find some interesting people that you know (colleagues, famous researchers in your field, organizations that you like). Read a few of their tweets and retweets and decide whether you like what you see. You can also search for the hashtag (go here if you don’t know what this is) of a conference that you have or have not attended and read what other conference attendees have shared about their conference experience. You now have a good enough idea of what Twitter is like. If you think you like it, then go to step 2. If you don’t like it, then decide that you will not join Twitter and stop reading this post.

 

Step 2: Getting started (30-45 minutes)

  • Depending on the goal you have with using Twitter, collecting lots of followers can be more or less important. If you only want to use Twitter to follow other people (not to advertise your work and get connected with others) you can skip the next bullet.
  • Start with uploading a photo and writing a bio. There are blogs about how to choose the best profile picture and how to write a good bio, but you can also use common sense (this takes less time). Then write three tweets and post them. This may feel strange to do because you don’t have followers yet, so you are tweeting to nobody. However, when people decide whether they want to follow you, they look at your previous tweets to see whether you are interesting enough to follow. Therefore you need some tweets to start with.
  • Start following some interesting people. There are two strategies if you don’t want to waste time on Twitter:
    • Follow a small selection of people who tweet the kind of things that are very interesting for you. Be picky by checking out someone’s previous tweets before you decide to follow them. If only 10% of what someone tweets is interesting, then do not follow this person. Unfollow people if it turns out that they are not so interesting as you thought at first. This ensures that your timeline is always full of interesting information for you.
    • Follow many potentially interesting people if you want to collect many followers yourself (again: this depends on the goals you have with using Twitter). If you follow someone, they get a notification and they may decide to follow you back. Retweeting or liking interesting tweets can also get their attention. If you follow this strategy and also want to read interesting stuff on Twitter without wasting too much time, you need lists. You can create a list easily and only add people who tweet the kind of things that are very interesting for you. Instead of reading your entire timeline you can just read the timeline of your list. This list can be kept private if you want, so people do not know whether they are on your list or not.

 

Step 3: Regular use (5 minutes per day)

  • Posting tweets can be done very efficiently:
    • Try to get a routine for posting certain things that you would normally email to your colleagues like interesting publications, conference announcements, call for papers, or job adverts. If you are already emailing someone a link then the extra effort of tweeting this is minimal.
    • If you read something interesting on a news or journal website, you can often click on the Twitter icon of the article and the tweet is constructed automatically. This will only take you a few extra seconds.
    • Tweet interesting things that you hear during conferences. You can do this during the conference presentation, so it won’t cost you any extra time. Also, you can tweet instead of making notes. Make sure to use the conference hashtag.
  • The thing that can consume most of your time on Twitter is reading tweets of others. Do not try to read everything that everybody that you follow is tweeting. Read part of your timeline (or the timeline of your list) for only a few minutes each day or on some days, retweet something interesting and then stop. There are also apps that warn you when you spend too much time on Twitter (e.g. RescueTime or MeeTimer), but it is probably not a good sign if you need these.

 

Do you have anything to add? Post a comment!

Last Friday, everyone involved in tobacco research in the Netherlands came together for the third NNvT conference in Utrecht. Besides researchers, there were also many practitioners and policy makers present. Although the Netherlands is a relatively small country, there were as many as 40 presentations of recent studies about smoking.

jizzo-bosdriesz jessamina-lie
marie-elske-gispen slide-prof-mackenbach

One of the major themes of the conference was vulnerable groups and socioeconomic inequalities in smoking. The day started with a keynote by Prof. Johan Mackenbach, who had the disheartening message that more tobacco control means more socioeconomic inequalities. An exception is reimbursing and targeting smoking cessation treatment to low socioeconomic status groups, like in the United Kingdom. Another exception may be tobacco tax increases, but Prof. Mackenbach and one of the other speakers of the day were not entirely sure anymore that tobacco tax increases reduce socioeconomic inequalities. What did became clear during the day is that new solutions are needed for vulnerable groups who experience more life stress and a more pro-smoking social network than others. Individual counseling with motivational interviewing remains important, but innovative approaches like rewarding smoking cessation are worthy of further investigation.

 

Almost one third of the presented studies dealt with tobacco control policy. The importance of societal support for tobacco control policies was emphasized many times. Several presentations focused on policies that are part of the ‘smokefree generation’ strategy of the Dutch Alliance for a Smokefree Society such as a tobacco display ban and outdoor school ground smoking bans. A very interesting finding was that a focus on protecting children from tobacco can unite people with very different ideologies and political beliefs in supporting these policies. Other presentations focused on the smoking ban in bars, for which one of the main messages was that smoking rooms undermine the effectiveness of the law. This is an important point, because the Netherlands Food and Consumer Product Safety Authority announced on the same day that the number of smoking rooms in bars has increased in the last year.

 

More literature reviews and meta-analyses were presented than during the previous NNvT conference. I think this is an excellent development. It is not always needed to start new research in the Netherlands, sometimes we can learn enough from previous research. Interesting was that quite a few researchers applied the realist review methodology. This is a relatively new method that examines how and why interventions or policies have certain effects instead of only examining whether and how much effects occur. It gives important insights into mechanisms and contexts, which can be used to improve tobacco control strategies.

 

A lot of research presented at the conference also focused on smoking cessation. A new clinical guideline for the treatment of tobacco addiction was released at the end of 2016, which made this conference an ideal opportunity to discuss the changes in these guidelines. An important topic remains how to increase commitment for smoking cessation advice and treatment among health professionals. Keynote speaker Prof. Daniel Kotz argued that health professionals should give opportunistic stop smoking advice without first selecting smokers who are already motivated to quit. E-cigarettes were also a point of discussion at the conference. Use among smokers seems to be motivated mainly by harm reduction and the intention to quit smoking, but there is now also evidence that Dutch youth who experiment with e-cigarettes are more likely to start using tobacco. The e-cigarette is not actively recommended as smoking cessation treatment in the new clinical guideline.

 

The day ended with a plenary discussion about priorities in Dutch tobacco research and the possibility of creating a national center of tobacco research with a shared research agenda. As part of the research agenda, the following topics were mentioned by the panel and public: smoking prevention, improving the reach and use of evidence-based interventions, social and political determinants of national and local tobacco policy, vulnerable groups and inequalities in smoking, and how to increase commitment among health professionals.

 

In sum, a very interesting conference with important discussions between researchers, practitioners, and policy makers. All attendees voted in favor of a yearly NNvT conference, so see you next year!

tweets-nnvt-2017

word-cloud-2016-publications-gvoAt the beginning of the year, universities look back at what they have achieved in the year before. Number of PhD defenses, number of publications, impact factors, amount of grant money obtained, etcetera. But what is more interesting than the numbers is the content of the research that has been done. At our department of Health Promotion of Maastricht University in the Netherlands the main topics that were published about in 2016 were: energy balance behaviors, tobacco smoking, and family planning. This blog contains very brief explanations about what our publications from 2016 were about. If you want to learn more, click on the links to the papers or ask your questions in the comments section below.

 

Energy balance behaviors

  • Dave van Kann and co-authors concluded that a school-centered multicomponent physical activity intervention holds the potential to activate children, but a comprehensive set of intervention elements with a sufficient magnitude is necessary to achieve at least moderate effect sizes. [link]
  • The same authors concluded that a multicomponent schoolyard physical activity intervention was effective in making children spend a larger proportion of recess time in light physical activity. [link]
  • And another study from Van Kann and co-authors examined the correlates of moderate-to-vigorous physical activity and sedentary behavior of children aged 8-11 years at schoolyards. Fixed equipment, such as high bars and soccer goals, teacher-initiated activities, and the presence of a ball games policy were correlates of more moderate-to-vigorous physical activity and less sedentary behavior. [link]
  • Ester Sleddens and co-authors found an association between parental impulsivity and (12-15 year old) child body mass index, which could possibly be explained by parenting styles and practices. [open acces link]
  • In a study from Dominique Reinwand and co-authors the behavioral change method ‘action planning’ is examined. The researchers conclude that increasing the motivation to change behavior should be prioritized in interventions concerning changes in health behavior before participants are asked to generate action plans. [open access link]
  • Jessica Gubbels and co-authors found that changes in greenery did not yield consistent positive results on physical activity and mental health among residents of severely deprived neighborhoods in the Netherlands. However, there were some indications regarding positive effects of greenery in certain subgroups. [link]
  • A focus group study by Kristina Romeike and co-authors focused on the beliefs and barriers that underlie socio-cognitive and planning constructs related to healthy eating and physical activity among lower-educated Dutch, Turkish, and Moroccan adults. The importance of cultural and religious factors appeared to be the most significant difference between the Turkish/Moroccan groups and the Dutch groups. [open access link]
  • Another publication by the same authors describes a protocol for the evaluation of two computer-tailored nutrition and physical activity interventions for lower-educated Dutch, Turkish and Moroccan women. One version is tailored to socio-cognitive variables (traditional tailoring), while the other is additionally tailored to ethnic identity (EI-tailoring). A randomized controlled trial will show whether the interventions are effective among these target groups and whether EI-tailoring is beneficial. [open access link]
  • Sanne Gerards and co-authors argue in their study that efforts to explain children’s nutrition behavior or weight often involve investigating the parent-child relationship. However, these behaviors are embedded in a broader system: general parenting and the family health climate. They recommend that more studies include a measure of the broader family system, in order to get a broader view of the mechanisms explaining child health behaviors and weight status. [open access link]

 

Tobacco smoking

  • Iman Elfeddali and co-authors reported on the results of a randomized controlled trial of a multiple-sessions Web-based Attentional Bias Modification (ABM) self-help intervention. The intervention turned out to be ineffective in fostering cognitive bias reduction and continued smoking abstinence. However, there were some positive effects in heavy smokers. [link]
  • A development protocol by Iman Elfeddali and Hein de Vries focuses on implicit pictorial assessment and modification tasks aimed at targeting cognitive biases underlying the pros and cons of smoking. The study resulted in 30 pro-con picture pairs matched on valence, arousal and complexity, which were used to develop a training. [open access link]
  • Karin Hummel and co-authors assessed trends as well as factors associated with acceptance of smoking in public places and implementation of home smoking bans in the Netherlands. Social acceptance of smoking restrictions increased, despite a suboptimal implementation process of smoking restrictions. Acceptance of smoking is still quite high for some public venues like bars. [link]
  • Another study by Karin Hummel and co-authors examined the external validity of the Motivation To Stop Scale (MTSS) among Dutch smokers. The authors conclude that the MTSS is an externally valid instrument to predict quit smoking attempts in the next 12 months. [link]
  • A randomized controlled trial by Mutaz Mohammed and co-authors aimed to examine the efficacy of a smoking prevention program which aimed to address smoking-related cognitions and smoking behavior among adolescents aged 13 to 15 from Saudi-Arabia. The prevention program reinforced non-smoking cognitions and non-smoking behavior. [link]
  • Dennis de Ruijter and co-authors describe the development of a web-based computer-tailored program and the design of a randomized controlled trial testing its (cost)effectiveness. [link]

 

Family planning

  • Matthijs Eggers and co-authors identified socio-cognitive determinants of primary and secondary abstinence intentions and of early sexual activity among 12 to 16 year old students of non-private South African high schools. The authors conclude that addressing socio-cognitive factors in order to motivate adolescents to delay sex is more likely to be successful before they experience sexual debut. [open access link]
  • Trends in teenage pregnancy and associations with other health risk behaviors in South African school-going adolescents were examined by Kim Jonas and co-authors. Girls continue to become pregnant at unacceptably high rates. Sexual intercourse among adolescents has decreased slightly. However, among those who are sexually active pregnancy prevalence rates have increased. [open access link]
  • Another study by Kim Jonas and co-authors was conducted to gain an understanding of nurses’ and midwives’ intentions to provide maternal and child healthcare and family planning services to adolescents in South Africa. Self-efficacy had a strong and positive association with the intentions to provide both maternal and child healthcare and family planning services. [open access link]

 

Other topics

  • Latifa Abidi and co-authors report on the results of a Delphi study among healthcare professionals and addiction prevention experts on strategies to overcome barriers to implementation of alcohol screening and brief alcohol intervention in general practice. [open access link]
  • Vera Heijnert and Claudia de Wilde published a short Dutch-language article based on their bachelor thesis research on health warning labels on alcoholic beverages that they performed at our department under my supervision. [link]
  • Hein de Vries published a commentary on corporate social responsibility (CSR) and public health. He concludes that monitoring, identification and combatting CSR activities should be an integral part of preventive medicine, public health, and health promotion. [link]
  • Hein de Vries also published a comment on a publication about self-efficacy by David Williams and Ryan Rhodes. He concludes that we need to skip the main factor paradigm but adopt the interaction paradigm providing more details under which conditions and for whom things work. [link]
  • Polina Putrik and co-authors explored whether age, gender or education influence the time until initiation of the first biological disease-modifying anti-rheumatic drugs (bDMARD) in patients with rheumatoid arthritis from Norway. [link]

 

Happy New Year!

Building SuccessHave you also noticed that there exist many blogs
about habits of successful people? They all claim to have a list of the most important habits of successful people, but how do you know which blog to trust? It’s simple, you just perform a content analysis of blogs about habits of successful people and then make a top ten based on all these blogs!

The ten most mentioned habits of successful people according to the first 25 blogs I found when I typed ‘habits success’ on Google:

#1: Reflect on your goals
The absolute number one habit of successful people (according to 16 out of 25 blogs) is reflecting on your goals. Think about what you want to achieve and work to accomplish that goal.

#2: Exercise
Although you may tell yourself sometimes that you don’t have time for exercise, the number two habit of successful people is working out. It helps to clear your mind and keep your body healthy. You can even reflect on your goals at the same time!

#3: Relax and meditate
Although becoming successful takes hard work (see habit #5), you also need relaxation. Plan vacations and spend time with your family in weekends. Also make sure you make time for daily relaxation. For example, by making meditation part of your daily routine.

#4: Planning and prioritizing
If you have reflected on your goals (habit #1), you need to plan and prioritize accordingly. Many blogs stress the importance of daily planning. For example, planning what you want to accomplish on the following day.

#5: Working hard
Surprisingly, only half of all blogs about habits of successful people mention working hard. This is perhaps because you should think first about which things you want to work hard on (habit #1 and #4). But as soon as you have your focus in mind, working hard is the thing to do.

#6: Read every day
Reading can learn you new things, get you inspired, and helps you to relax. Do you need to read every day? That’s what 11 out of 25 blogs that I analyzed say.

#7: Wake up early
Set the alarm at 6:00 AM seven days a week, because waking up early will make you successful. Most blogs do not really explain how this works, they just mention some names of successful people who wake up early each day. Let me do the same: Barack Obama, Richard Branson, Jack Dorsey, Larry Schultz, Tim Cook, Robert Iger, Marissa Mayer, and Ursula Burns.

#8: Eating healthy
Eating healthy gives you energy, prevents diseases, keeps you in shape, and generally makes you feel better. This is a habit that everyone should have, not just successful people.

#9: Sharing
Successful people don’t keep everything they own for themselves. They share their success with other people. Sharing can be done in different ways, such as giving to charity, sharing ideas, giving advice, and volunteering.

#10: Networking
In business and in academia, your network is everything. So spend time talking with people, listen to them, and learn from them. One day you may end up in a business or working relation with them.

 

Sources: 10 Morning Habits Successful People Swear By, 10 Habits of Ultra Successful People: The Secret Sauce to Success, 5 Daily Habits of Highly Successful People, 16 Rich Habits – Your autopilot mode can make you wealthy or poor, 11 Essential Habits for Success, Fifty Habits of Highly Successful People, 12 Weekend Habits of Highly Successful People, 11 habits of highly successful people, 6 Daily Habits of Hugely Successful People, Hack Your Day: Morning to Nighttime Habits of Highly Successful People, 10 Habits of Successful People, 9 Success Habits of Wealthy People That Cost Nothing, 20 Habits That Will Make You Highly Successful, 11 Daily Habits of Exceptionally Successful People, 12 Powerful Habits I Have Stolen From Ultra-Successful People, 7 Great Habits Of The Most Successful People, 20 Habits for Success I Learned Working for Two Billionaires, 43 Experts Reveal Their No. 1 Daily Success Habit, 20 productive Habits of Successful (and Very Wealthy) People, Eight habits of highly successful people you can try today, How to Master the Habits of Successful People, 3 daily habits of the world’s most successful people, Habits Of Highly Successful Men, The 10 Must-Have Success Habits, 10 Habits of Successful People.

Shifting focus

During the past year, I have been shifting my focus to include other research topics than smoking cessation, I have learned new research methodologies, and started focusing more on teaching. Is it a smart move to change so much and ‘start over’ with having to learn many new things? I honestly don’t know. Is it always a conscious decision that these kinds of changes happen during your academic career? Definitely not. But more importantly: Is it fun and interesting to learn new stuff? For me it certainly is!

My new experiences
challenges-experience-signAfter a PhD study and a first post-doc study on the impact of tobacco control policies on smoking cessation, I started a second post-doc study last year on the impact of economic recessions on illegal drug use. A very interesting study in which we used the realist review method to describe the mechanisms that explain how economic recessions may change individuals’ illegal drug use. A publication on this topic is on its way, and I will definitely mention it here when it’s published. Meanwhile, if you are interested in the realist review method (which is relatively new and gaining popularity fast), read the book or paper by Ray Pawson. If you are interested in our project, check out our website or this short video.

After years of mainly focusing on doing my own research at Maastricht University, I am now supervising four PhD students there and I became a lecturer at a University of Applied Sciences (de Haagse Hogeschool). The PhD students that I supervise all study (different aspects of) smoking cessation, but at the Haagse Hogeschool I teach research methodology at the study program Nutrition and Dietetics. It turns out that I really like the supervision and teaching role and I also like it very much to learn things about Nutrition and Dietetics.

Finally, I started a few months ago with a new research project about health behavior change among multi-problem families. Multi-problem families have to cope with multiple problems and stressors in their family lives, such as socio-economic problems (e.g. financial problems, unemployment), psycho-social problems (e.g. domestic violence, psychiatric disorders), and problems associated with the upbringing of their children (e.g. neglect, maltreatment). In this project we examine smoking behavior, but also alcohol abuse, unhealthy nutrition, and physical inactivity. I have now started a series of qualitative interviews with members of multi-problem families to talk about their experiences with health behavior change. Both the new topics and learning to do qualitative research has been very inspiring.

What about you?
Should you change research topics or methods after your PhD or should you stick to what you know? It’s hard to say. Changing topics might increase your chances when you are looking for a new job, because you can show that you are versatile. However, sticking to your topic might increase your chances when you are applying for a grant, because grant reviewers and funding organizations have the trust that you know what you’re doing. But you should probably not worry too much about this, because more often than not it isn’t a conscious decision. In my case, I wrote two large grant proposals last year. One was about tobacco control policy and one about health behavior change among multi-problem families. The last one was accepted and the first one was not, which made the choice for me what I was going to do.

Time for Change - ClockIf you do have the choice, I would say: Go for it! It is fun and interesting to learn new stuff. Sometimes you feel a bit like you have to ‘start over’, like you are in the first year of your PhD again. But why would you be afraid of that? And you might feel like this, but in the end you have learned a lot of research skills already, which makes you learn and pick up new things much faster than when you just started. Are you considering a change to an entirely different research field? Then this blog post might be of interest to you.

Should you be afraid to lose everything you build up in the years that you worked on your previous topic? My experience is that you don’t have to stop working on your previous topic when you are starting new things. I am still involved in many smoking cessation research projects and in the network that comes with that. You don’t have to work twice as hard to work on two (or more) topics, you just have to learn to divide your attention.

As always, I am interested to learn about other people’s experiences. Feel free to post your experience, thoughts or questions below.

A few weeks ago I read aBusy-cover2-193x300 short interview with Tony Crabbe about his book ‘Busy – how to thrive in a world of too much’. Normally, I wouldn’t have bought the book, because I seldomly make time to read books. But the timing was right because I was going on a skiing vacation and I would have plenty of time to read a book on how to become less busy. So I ordered the book and took it with me on my skiing trip. It turned out to be a great read that I would recommend to everyone, but especially to early-career academics, although the book is not written for academics at all.

Crabbe is a business psychologist and many examples in the book are about commercial companies. But it is written for people who can (to some degree) make their own choices on what kind of work they do, how much they do, and/or how they do it. My guess is that this is true for more people in academia than in business. Crabbe uses numerous scientific theories and principles to back up his recommendations and he describes in a simple but effective way how the brain works and that it needs recovery periods and cannot deal with constant busyness. This makes his argumentation quite convincing for academics.

Of course Crabbe realizes that the people who want to read his book are too busy to read books. Therefore, the book brilliantly starts with ten short and simple suggestions that help to create enough time and space to read the book. For example: turn off the email notifier of your computer and phone, cancel a meeting, create a ‘braindump’ (something that you always carry with you on which you can easily jot down ideas and things you shouldn’t forget), and, last but not least: smile more.

The book is filled with recommendations that can help you to change how you do your work and I will not repeat all of them here. An eye-opener for me was the proposition that time management is not a real solution. Time management helps you to do more, but there is too much to do, so it will only make you busier. Crabbe recommends to shift your focus from getting things done to making an impact and differentiating yourself. Instead of feeling that you have to be in control again, you should let go of your need for control and gain a sense of mastery by making choices and managing your attention. Most people in academia have at least some freedom to choose on which topics/projects they work. Especially when you have obtained your PhD and start working on research that you have designed yourself. At that point, Crabbe recommends to make more ‘which’ choices (‘which things do I want to focus on?’) and less ‘whether or not’ choices (‘do I want to do work on the project/task that someone else asked me to work on?’). You cannot control the ‘whether or not’ questions that other people ask you, but you can gain mastery by focusing on the projects and tasks that are important to you.

After reading a book like this it is easy to feel very inspired to change a lot of things but never really do it. Therefore, one of the last chapters of the book deals with the difficulty of behavior change. Crabbe recommends to plan to change only one small thing in your behavior after reading the book and gives tips and tricks on how to ensure that you will really change your behavior. What I want to change after reading the book? I supervise several PhD students and I get a lot of email, so if I’m not careful I fill my days completely with meetings and email without working on my own research projects and I do want to (and need to!) work on my own research projects. Crabbe recommends to get really clear and specific about the behavior you want to change: I want to start each working day with a period of email-free and meeting-free time to work on my own research. Crabbe recommends to start really small, so I will do this for at least half an hour each day before opening my email and looking at my ‘to do’-list. One way of ensuring that you will stick to your promise is using social influence (hence this blog!). Finally, you should get back on the horse if you fail, which was what happened to me when I came back from my skiing trip and felt overwhelmed by a full email inbox with a lot of ‘whether or not’ questions which I started to answer right away. This week is already going a lot better! And my next goal? Making more time to read good books!

I am currently involved in setting up a research study on smoking cessation in Dutch companies. Smoking cessation group therapy is an effective method to quit smoking and it is sometimes used in a company setting. Although this is a scientifically proven effective smoking cessation method, not everyone who participates succeeds in smoking cessation on the long term because tobacco use is very addictive. Click here for our brochure with more information about study participationReason for us to test novel approaches to increase smoking cessation success rates.

Previous research from the United States has shown that rewarding employees for smoking cessation success with monetary incentives increases their success rates. The Dutch Cancer Society wanted to know whether such an intervention could also be effective in the Dutch company setting and thus funded our research that is carried out at the Department of Family Medicine of Maastricht University.

Although rewarding smoking cessation success may be effective in most cultures, it is not accepted everywhere. The Dutch company setting and Dutch social norms towards smoking are very different from the United States. In the Netherlands, giving smoking employees monetary incentives will be considered tremendously unfair for non-smoking employees. To illustrate, a recent opinion poll showed that only 9% of the Dutch population agreed that smoking cessation support should be fully reimbursed by health insurance. People argued that smokers have chosen to smoke themselves and thus it is their own fault that they need support. It is of course questionable whether people chose to smoke, because most people start when they are young and then get addicted, but not a lot of people in the Netherlands are aware of that.

In our research we will not give smoking employees monetary incentives for successful smoking cessation. Instead, we will reward them with coupons that they can exchange for healthy products, getaways, activities, and gifts. Also, the monetary value will be lower than what was done in the US in order to test an intervention that is more culturally appropriate for the Netherlands. We will not only examine the effectiveness of the intervention, but also the cost-effectiveness. This is of course vitally important considering the dominant sentiment that smokers should pay for smoking cessation themselves and that smokers don’t need to get rewarded for quitting.

We are now in the final stages of preparation of the study and will start with the smoking cessation group therapy sessions soon in numerous Dutch companies. We work together with highly experienced smoking cessation counselors who provide evidence-based group sessions. If you know a company that may be interested in participating in our study, then please contact us. If you want more information about study participation you can find our brochure through this link (in Dutch). The protocol of our study is published in BMC Public Health.

Every PhD program has an academic writing course. And numerous blogs have been written about how to write journal articles, how to write with co-authors, and even about conflicts about author positions. However, nobody teaches you how you can be a good co-author. After writing one or more articles yourself you may be asked to be a co-author on someone else’s paper. This blogs contains six important tips on how to handle this responsibility.
Co-authorship

Before you say ‘yes’
You are probably flattered for being asked as a co-author. But think for a minute before you say ‘yes’. Being a co-author has appealing benefits. Someone else (the first author) does most of the work, you give comments on a few drafts, and you have an extra publication on your publication list. A co-authorship can also extend your academic network, it may give you the opportunity to work on additional research topics, and it may broaden your methodological or statistical knowledge. However, you should realize that there is a considerable time investment. More often than not articles take more than a year before they are published. Co-authors should not only give some bright ideas at the beginning of the writing process, but they should also be available once the first author is working on a revision for a journal. It may be a good idea to discuss expectations about your contribution before you start. Being a co-author can range from helping out with the analyses and writing sections of the article to just commenting on two or three drafts of the article.

 

Six tips for being a good co-author
1) First of all: be friendly and respectful when commenting. Do you remember the first time you sent your article to your co-authors or supervisors? You probably felt a little scared about what they would say. Although you may not be co-authoring someone’s first article, it can never hurt to be friendly. This may seem like unnecessary advice, but it happens a lot that people forget to be friendly because they are focusing on what should be changed to a paper. Try to pinpoint what you like most about the article and tell this to the first author. And try to be helpful when making comments. Do not only say that something is wrong, but also come with solutions on how to fix things. Finally, if you have a critical remark you should definitely make it, but NEVER USE CAPSLOCK or multiple exclamation points!!!

2) Rewriting parts of the article is often not a good idea. Make you sure you never rewrite parts of the article when you are asked to comment on a very first draft. Using comments instead of editing in the text or simply writing your main comments in an email is often enough for a first draft. You or other co-authors may suggest things that change the entire article and thus the texts that you would rewrite will change too. In later stages, editing is okay, but always keep in mind that this is not your paper. People have personal preferences and a personal writing style which you do not have to change.

3) It can be quite discouraging to get more than thirty comments on your draft paper from one co-author. See whether you can give some overall comments instead of giving the same comment on several places in the article. It may also be helpful to separate major comments from minor comments. Major comments can be given during a meeting or in the body text of an email. And minor comments can be handed out on paper at the end of the meeting or can be added to the attachment of the email.

4) Don’t be shy to tell that you didn’t understand something that was written in the article. Oftentimes, this does not mean that you are not smart enough but that the first author did not properly explain. The first author fully understands what was done and thus misses the fact that the explanation in the text is not clear. It is very helpful when you point that out.

5) Try not to delay the process. If the first author gives you a deadline, try to stick to it. If you really cannot do it, tell the first author as soon as possible. Perhaps the first author doesn’t mind when you send it a few days later or when you skip a round. Also, for a smooth process with multiple co-authors, it may be helpful to respond to all co-authors when emailing about the article. You can add your comments to the draft in which another co-author already added comments and you can respond to comments from other co-authors if appropriate. If the first author asked for your opinion on a specific section of the paper, make sure you don’t forget to give it.

6) Know that there are international rules for when you can be mentioned as a co-author and when not. You should have made a substantial contribution to the conception and design of the study, or analysis and interpretation of the data, AND you must have drafted the article or revised it critically for important intellectual content, AND you should provide final approval of the version to be published. If you know you don’t have the time or expertise to do these things, don’t say ‘yes’ to the co-authorship. If you find out after you have said ‘yes’, just explain to the first author that it would be better to mention your name in the acknowledgements.

 

Do you have any other important tips for being a good co-author? They can be added in the comments section below.

The SRNT Europe conference was organized in Maastricht last week. I really liked the conference, because it had a very interesting and diverse program. Below is a short account of what I thought was particularly interesting to hear on the conference.

Maastricht

Multidisciplinarity
The theme of the conference was ‘the bigger picture: towards multidisciplinarity in nicotine and tobacco research’. The theme was especially present in the special symposium about e-cigarettes. Four presenters told about e-cigarettes from different perspectives. The epidemiological perspective (by Esther Croes), the clinical perspective (by Pierre Bartsch), the public health perspective (by Luke Clancy), and the producer perspective (by Gerard Hastings). This gave a very complete overview of where we stand in terms of evidence and practice. For me, it was interesting to hear more about the clinical perspective. As researcher you are inclined to wait until enough evidence is available to make an evidence-based decision about whether to recommend e-cigarette use. However, clinicians get questions about e-cigarettes from their patients right now and need to recommend something before all evidence is available. Pierre Bartsch explained he does advise the use of e-cigarettes for smoking cessation, but only when everything else fails and the patient asks about e-cigarette use.

Harm awareness
Several keynote speakers addressed the topic of awareness of the harms of smoking and how we can improve this. Robert West advised us to not just tell people about the harms of smoking, but telling it in a way that is compelling and motivational. For example, use the statistic that for every day you carry on smoking after your mid-thirties, you will lose an average of six hours of life. Paul Cairney had a similar message: use simple messages that people can understand and remember. Paul Aveyard argued that we need to learn what smokers believe first before we can come up with effective communication strategies.

In an ITC Project symposium, striking findings about harm awareness of Dutch smokers were presented. Compared with 15 other countries studied, the Netherlands had the lowest percentage of smokers reporting that they often think about the harm of smoking to themselves or others. A report in which these and other findings were reported was distributed at the conference.

New ideas
There were some interesting new ideas put forward on the conference. Amanda Amos argued for a tobacco industry levy in her keynote lecture. Although the idea of a levy is not new, Amanda framed it as an intervention to reduce inequalities in smoking. The money that is raised with the levy should be used to fund measures to help smokers quit and it should be distributed in proportion to the volume of tobacco sales in different areas of countries. This way, the areas where tobacco sales is highest – the areas where most disadvantaged smokers live – get more help.

The keynote lecture from Jacqueline Vink was about the genetics of smoking behavior. She proposed to examine gene-environment interactions. According to Jacqueline, understanding the balance between genetic and environmental causes may hold the key to further reductions in smoking.

Furthermore, one of the symposia was about smartphone apps for smoking cessation. There are hundreds of smartphone apps available, but they are often not evidence-based. Ildiko Tombor presented an innovative factorial design (with 32 experimental groups) to test the additive effects of different components of a smartphone app.

Finally, new at this SRNT conference were practical workshops as part of the parallel sessions. Participants could learn about missing data analyses, economic evaluations, dealing with the media, and about writing and publishing scientific papers. I only attended one of them, but think it is a great idea and it would be nice if future conferences could also offer similar workshops.

Finally
I hope you enjoyed the conference as much as I do. Or, if you have not attended the conference, I hope you feel you were a little bit there too after reading this blog.

Some tweets from SRNT Europe:

Tweets SRNTA Dutch opinion piece about the SRNT conference published in Dagblad de Limburger can be read here.

I am not totally sure why it first happened, but for the past few years I have been regularly asked by friends and family to help modernize their resume. Some of those that I helped were invited for a job interview soon after that and got complimented about their clear resume. This helped spread my reputation of ‘resume modernizer’ and I got asked by more friends and family to help them. So, I thought: why not write a blog about it and maybe help even more people out?

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1. Make it clear
Once upon a time a resume just needed to contain information about your work experience and education. But times have changed. Nowadays, a resume needs to be scannable. Sometimes, hundreds of people apply for one position. The selection committee then may only have a few seconds up to a minute to skim over each resume for the first selection. They don’t have time to read the whole thing line by line. If your resume is structured and clear, the selection committee will know immediately where they can find the information that they are looking for.

Make clear subheadings on your resume, with the most important information on the first page. Whether your education or your work experience is most important, depends on your experience. If you nearly or just finished your education, you should start with that. But if you finished your education years ago and have relevant work experience, start with your work experience.

A resume should have enough white space (for readability), should not have spelling mistakes or track changes, and should use a readable font. Send your resume in the form of a pdf file, which makes sure that things look the same on the computer screen of the selection committee as it looked on your own screen.

2. Make it personal
A modern resume starts with a personal profile or summary statement. It is a short text that explains who you are. You can mention your past experience, your main professional motivation, your professional interests, or your skills, but do not make it too long. There are several good dedicated blogs about writing a personal profile, for example this one and this one. But most importantly, you should write something that fits with who you are. Place your personal profile immediately after your personal details (name, contact information, etc.) and before your work experience and education.

In some countries, modern resumes contain a picture of the applicant. You should probably not include a picture if you are applying for a job in the US or the UK (unless you are an actor or a model), but you should seriously consider this if you apply for a job in Germany or the Netherlands. If you do it, make sure it is a good picture, in which you look confident and reliable, and in which you wear an appropriate outfit for the job you are applying for. Make sure the picture is large enough so people can see it, but do not make it so big that you seem vain.

Another way to personalize your resume is to do something more with your work experience section. Make sure it contains more information than the name of the company and your job title. Tell what YOU did in your jobs, not just what everyone with that job title does at that company. Write down your specific tasks and achievements with bullet points or in full sentences, depending on your personal preference, but do not make it too long. You can read more about good job descriptions for resumes here and here. You can also do this for your education. Write down what your thesis was about (if this is still relevant) and what specialization you did.

If you want, you can also include your hobbies on your resume. This may help to make you stand out from the other applicants and lets your personality shine through. However, if you only have hobbies that everyone has and are not memorable (reading, walking, gardening, dining with friends), just leave them out. Also, make sure this kind of personal information is not too obtrusive in your resume. A single line with three to five hobbies at the end of your resume is enough.

3. Make every word count
A standard (non-academic) resume is one or two pages. Early in your career, one page is enough. Therefore, it is important to make every word count. For every detail on your resume, ask yourself whether it is needed. For most jobs, your gender, marital status, birth place, nationality, and driver’s license is not relevant. If you have college education, you can leave out high school. If you are 35 years or older, you no longer need extracurricular activities on your resume that you did when you were in college. Irrelevant work experience (student jobs, summer jobs, and internships) can be left out once you have enough relevant working experience. The sentence ‘references available on request’ is also pretty redundant.

If you have left all irrelevant things out of your resume, you have space to include extra relevant subheadings, such as courses, language skills, committees, or publications (depending on your work field). Make sure there is more than one thing under one subheading or leave the subheading out. Additionally, make sure there is at least one thing recent under the extra subheading or leave it out. It looks better if you don’t have a course list on your resume than to have a course list that shows that you did a lot of courses five years ago and then stopped doing courses. A computer skills section that only contains basic computer programs (Word, Excel, Powerpoint), can better be left out.  Do not use the subheading ´other´, this will not spark anyone’s interest and thus will simply not be read.

4. Customize
A resume should be customized for every job you apply for. This does NOT mean you should lie, but you can emphasize different aspects of your experience. Read the job description for which you apply carefully to know what the selection committee is looking for.

If you apply at a trendy company with mostly young people or if you apply for a creative position, consider designing a creative resume in the form of an infographic or even a video. Don’t do this if you apply at a very traditional company for a position that does not involve creativity.

If you apply for an academic job, forget about the one or two page maximum. An academic CV can get lengthy (depending on your experience), because you are expected to list all received grants and published papers. If you have more than two pages, make sure you use page numbers (one of four, two of four, etc.) and a footer with your name, so the pages don’t get mixed up in the printer.

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Of course, every job interviewer has personal preferences and some of them may not even like a modern resume. There are also country differences in what is acceptable for a resume. I have written this blog in English, but I am mostly familiar with Dutch resumes. I expect that many of the tips and tricks above will apply to resumes from other countries, but invite you to leave a comment below if you know of any differences. Also, please leave a comment if you have other tips and tricks!

billige zigarettenEarlier this month, the scientific journal Tobacco Control published a study on cross-border purchasing of tobacco products among adult cigarette smokers in the European Union. The main finding in the paper is that cross-border tobacco purchasing is more prevalent in countries that are bordered by countries with lower tobacco prices (most notably France, Finland, Germany, and Austria). For each Euro price difference, the odds of making a cross-border purchase increases by 15%. Therefore, the authors recommend to reduce differences in cigarette tax and price within the EU and to implement stricter limitations on the quantity of cigarettes that persons may take from one European member state to another. Besides these general findings, I also thought there were some important findings for the Netherlands in this study.

Dutch smokers buy tobacco abroad because they are often abroad
The fact that cross-border tobacco purchasing is higher in the Netherlands (50% of smokers in last year) than on average in Europe (26%) is not a reflection of smokers crossing the border because of cheaper cigarettes. Dutch people are just more often in other countries, probably because our country is so small and thus a lot of people live close to the border. Of the smokers who report cross-border tobacco purchasing in the Netherlands only 35% report to do this because of a cheaper price compared to 56% in Europe on average. 75% of Dutch smokers who report cross-border tobacco purchasing just needed tobacco while they were in another country.

Dutch smokers who buy tobacco abroad do not buy large quantities
Dutch smokers buy less of their annual tobacco consumption in another country than the average European smoker. In the Netherlands, 10% reports to purchase more than half of their tobacco consumption in another country, while this is 15% on average in Europe. Moreover, 11% in the Netherlands reports to purchase more than 5% but less than half of their tobacco consumption in another country, compared to 21% on average in Europe. So it seems that most Dutch smokers just buy their tobacco abroad when they are there anyway and they don’t load their trunk or suitcase full of tobacco, but just buy what they need at that time.

Buying tobacco abroad is not common among young smokers
Buying tobacco abroad because of the cheaper price is less common among younger smokers (15 to 24 years old) than among older smokers. Especially smokers aged 55 years and older buy tobacco in another country because it is cheaper. Also, buying tobacco abroad because of the cheaper price is more common among highly educated smokers. So we should not worry that increasing tobacco taxes in the Netherlands does not decrease smoking among youth and lower educated groups because they all just go to Belgium to get cheaper cigarettes. It is much more likely that many young and lower educated smokers quit using tobacco due to increased tobacco taxes, while a few older and higher educated smokers keep smoking and buy their tobacco abroad because it is cheaper.

This week, we had the closing conference of our European research project about the impact of tobacco control policies on socio-economic inequalities in smoking (the SILNE Project). In the past three years, our collaborative has performed systematic reviews, trend analyses, country comparisons, and social network analyses. These were all presented at the European Parliament in Brussels.

For me, the three most important outcomes from the project and the conference are the following:
•  It seems difficult to reduce socio-economic inequalities in smoking with tobacco control policies. But this does not mean that tobacco control policies cannot reduce smoking among low socio-economic groups. Among both youth and adults, most policies benefit all socio-economic groups.
•  Increasing tobacco taxes seems to be the policy with most potential to decrease socio-economic inequalities in smoking. This is true for both youth and adults. For youth, there is some evidence that age-of-sales laws and social network-based approaches may also be able to do this. And for adults, cigarette marketing controls, targeted media campaigns, and targeted smoking cessation services may be able to decrease inequalities in smoking.
•  If future tobacco control policies are to reduce inequalities they probably must be specifically designed to do so. The question remains how we can do this. One possibility is to increase the reach of (cessation) policies and media campaigns among low socio-economic groups to compensate for lower effectiveness among this group. However, future research should also find ways to increase the effectiveness of interventions among low socio-economic youth and adults.

Given the choice between reducing smoking and reducing inequalities in smoking, most tobacco control advocates would probably choose for the first option. However, we should not forget that when we reduce smoking further and further, the group of smokers that is left is increasingly less educated with lower incomes. Health policy plans and endgame strategies should thus always consider how socio-economic inequalities in smoking can be tackled.

Picture of the SILNE conference in Brussels, december 2014.

Picture of the SILNE conference in Brussels, december 2014.

All presentations of the SILNE conference can be downloaded here.

This week, the Stoptober campaign was launched in the Netherlands for the first time. This campaign originated in England and stimulates people to quit smoking for 28 days in October. The Netherlands is called upon to supportstoptober_800x415 smokers who want to participate. This idea fits with the policy of the Ministry of Health to encourage and reimburse smoking cessation assistance. However, last month research from the Dutch research institute NIVEL revealed that the average Dutch citizen believes that government reimbursement for cessation assistance is not necessary. That’s a shame, because smoking is so addictive that a lot of smokers have difficulty quitting on their own. Professional support, but also support from their social network, is therefore extremely important. It would be good when Stoptober could stimulate people to give such support.

Stoptober is not just any idea from a creative advertising agency that had to come up with something new. It is based on three psychological principles about behavior change. Principal 1: the importance of social networks and the fact that changing is easier if people do it together. Principle 2: the fact that long term behavior change can be reached with realistic intermediate goals. Principle 3: the instability of the human motivational system that needs different forms of support to reach lasting change. This is where the idea came from to quit smoking with as many people as possible (principle 1) for 28 days (principle 2) and with support through national and social media, by famous and regular Dutch citizens, and with an app or personal professional assistance (principle 3).

England launched the Stoptober campaign for the first time in 2012 and research has shown that the campaign yielded 350,000 extra quit attempts. These people did not all quit for good. Four weeks abstinence makes you five times as likely to stay quit. But the majority can still not quit smoking in one try. Why is that? Cigarettes contain nicotine. This is an addictive substance that reaches your brain within a few seconds after lighting up. If you are addicted to nicotine you get withdrawal symptoms if you don’t smoke for a while. You are, for example, irritable, anxious, you have difficulties concentrating, and you are not sleeping well. By starting to smoke again these symptoms disappear, which makes it very difficult to stay quit. Yet, people benefit much if they finally succeed: they feel fitter, they taste and smell better, ánd they live longer. Reimbursing professional cessation assistance is, thus, the logical thing to do.

My own research showed that the campaign ‘Really quitting smoking can be done with the right help’ from 2010 and 2011 ensured that almost twice as many people quit smoking in the Netherlands. This campaign was about reimbursement of cessation assistance by the government. I personally think that this campaign gave people the impression that the government understands how hard it is to quit smoking and that the government, therefore, wants to offer support. Of course it would be even better when people do not only experience this understanding and support from the government, but also from society as a whole. Stoptober may be the beginning of that.

More information about the Dutch Stoptober campaign can be found on stoptober.nl

Translated from:
Nagelhout, G. E. (9 september 2014). Steun rokers die willen stoppen! [opinion piece]. Dagblad de Limburger.

Last week we had a meeting with PhD students and PhDs from our department at Maastricht University. We talked about how to plan your PhD project efficiently and effectively and also about how to plan for after your PhD project. Read the recommendations from me and my colleagues in this blog.

Planning your PhD project
A great recommendation that we got from a report that was published last year by our research school is to “be the captain of your ship”. Because you are stakeholder #1 in your PhD project and your supervisors are there to help you achieve your goal, you should take charge.  Taking charge of your own project also helps to keep you motivated.

Another very important thing is that you plan your project and your time well from the start. Although your project plan and time schedule may change all the time, try to plan ahead and anticipate when busy and less busy periods are. Perhaps you can get assistance for the busy period, but this can probably only be arranged when you ask for it in time (hence the importance of planning). Also, if you see the less busy periods coming (right after an important deadline?), you can plan a well-deserved vacation. Vacations are needed to charge your battery so that you can perform better when the next busy period arrives.

Realize that writing, submitting, revising, and resubmitting scientific papers takes lots of time. If your project planning involves three years of preparation, intervention development, participant recruitment, and data collection, and you have only the last year left for writing papers you may not have a publication list yet (only a list of submitted papers) when you are finished with your project. That does not help when searching for a job in academia.

Do not forget to plan time for writing, revising, and printing your PhD thesis. Even if you can bundle your papers to form your PhD thesis (which is common in the Netherlands), you will have to write an introduction and discussion chapter. This may take more time than you realize. Plan ahead for this and start in time.

Your PhD defense will take some preparing too. See one of my previous blogs to read my recommendations.

Planning for after your PhD project
Although you are probably not specifically asked to write grant proposals while you are doing your PhD project, you will need grant writing experience immediately after obtaining your PhD. Therefore, you cannot begin too early with this. Being successful in getting grant money is an important predictor of being successful in getting grant money. But how should you get started then? The key is to start small. Try to obtain a small grant for a visit abroad or for organizing a small symposium while you are still working on your PhD project. This will give you a small ‘track record’ of obtaining grants that will help you obtain larger grants and jobs after your PhD project.

Experience working abroad is extremely important for an academic CV. Read my previous blog about why you should do an international research visit. When you are abroad, try to make the most of it by visiting other universities or institutions that are important for your research field, meet people, and perhaps present about your research. This can be the start of interesting international collaborations. It is best if you can also show that you have academic ‘output’ from your visit abroad. Perhaps you can write a paper with the professor that you are visiting. This also gives you experience with working with others than your supervisors, which is also important for your CV and may otherwise be difficult to achieve.

If you are almost ready with your PhD project, you are probably trying to find a new job. It might be good to be prepared for what potential employers will see when they google your name. You can do some online personal branding to make sure you like what they find. You can make your own personal website. This can be done for free and does not have to be hard (see for example my personal website that is quite simple, but effective). Also make sure that your LinkedIn profile is filled in and contains a good photo and perhaps join an interesting LinkedIn group. Maybe you can already get some press coverage during your PhD project by asking your university whether they can do a press release when you have published a paper with important findings.

Finally, do you think your PhD thesis is an impressive piece of work? Then nominate yourself for a thesis award. If you need to be nominated by others, just ask your supervisors. Sometimes there are not a whole lot of people nominated for these kinds of awards and your chances of obtaining one are pretty good. An award is a very nice addition to your academic CV, so don’t be shy!

To do list (PhD Comics)

Last week, I attended the European Conference on Tobacco or Health (ECToH) in Istanbul, Turkey. In this blog I would like to share with you my personal observations, things that got me thinking, and lessons that I learned during this conference.

The conference started with the presentation of the Tobacco Control Scale, an exciting moment for each country. The United Kingdom “won the first prize” for doing a terrific job in implementing tobacco control policies and campaigns.

Of course, there was a lot of attention for the new European Union Tobacco Products Directive (TPD) that had been adopted two weeks before the conference. For me, the most interesting part of hearing about the TPD was the things that convinced members of the European Parliament (MEPs) to move forward. Linda McAvan told us that international comparisons between the EU and for example Australia and the USA convinced MEPs that Europe is lagging behind and that something should be done. Additionally, Anca Toma Friedlaender explained that MEPs did not understand the need to have large pictorial health warnings on the top of the pack until they were shown pictures of how much difference this makes (see below).

 

Difference between 75% warnings on the top or 50% warnings on the bottom of the pack

Plain packaging was implemented in Australia in 2012 and is considered now in Ireland, New Zealand and the United Kingdom. No new results from Australia were released during the conference, but Simon Chapman noted that the tobacco industry passed the ‘scream test’. Never before had he heard them screaming so load, they may be more afraid of plain packaging than of tax increases.

How and when can we end the tobacco epidemic? This question was asked several times at the conference. Anna Gillmore said that we cannot realize an endgame without adressing the tobacco industry. Florence Berteletti added that we need champions and political will. Cynthia Callard mentioned that we need to work globally, because that’s what the tobacco industry does. Several people expressed that they did not like to use the term endgame because of connotations with the Hollocaust. An alternative was proposed that could be used for the public: making smoking history.

There were also a lot of presentations and discussions about e-cigarettes at the ECToH conference. Although opinions about what to think of e-cigarettes differed widely among speakers, I think there were four things that people agreed upon: 1) Some form of regulation of e-cigarettes is necessary, 2) Adults should have controlled access, 3) Tobacco industry involvement in the e-cigarette market is worrying, and 4) Use of e-cigarettes and effects on adults and children should be monitored.

In a session about smoke-free laws, the advice was given to implement article 5.3 of the Framework Convention on Tobacco Control (FCTC) first, before implementing smoke-free laws or other policies. Article 5.3 says that tobacco control policy should be protected from tobacco industry influence. When this protection is in place, you don’t have to fight the tobacco industry over and over again when implementing other policies. Sylviane Ratte explained what the success ingredients are for smoke-free laws: 1) Political will and sustained commitment, 2) Clear, simple, enforceable, universally protective laws, 3) Information and communication to get the population ready, 4) Consultations, coalitions, stakeholder and civil society involvement, 5) Will, confidence and capacity to enforce, and 6) Countering tobacco industry and other opposition.

The conference ended with a panel session about advocacy and media campaigns. With respect to advocacy, it was advised to try to keep tobacco in the news all year round. Becky Freeman explained that using social media is important, but that you need to enhance the appeal to participate in the campaign and actively drive traffic through continuous promotion. Several examples of media campaigns were shown from France, United Kingdom and Ireland. Some were about the tobacco industry and others were about lives lost to tobacco, but they all had one thing in common: they showed the thruth about smoking without showing gory graphics and without patronizing. Some commercials that were shown were highly emotional, which has been shown to work best ánd to work among lower socioeconomic status groups. Two examples can be found below. To be honest, I didn’t like watching these commercials on the big screen during a conference, because they got me into tears by being so shockingly real and recognizable when you have lost someone to smoking. But still, I really hope to get similar commercials on television in the Netherlands someday, because I think it is important that the thruth about smoking is shown.

 

 

 

Thank you to the conference organizers for a wonderful 6th ECToH conference. And thank you to the speakers and other conference attendants for al the valuable lessons I could learn from you. Until next time!

For the past couple of years, my research has focused on socioeconomic inequalities in smoking. As part of the SILNE Project, I’m studying whether tobacco control policies and campaigns can stimulate smoking cessation among smokers with low, moderate, and high education or income. This is important, because people from low and moderate socioeconomic status (SES) groups begin smoking more often and quit smoking less often than people from high SES groups. Differences in smoking prevalence between these groups are increasing in several Western countries (including the Netherlands), which causes SES differences in disease, disability and death. This is definitely not a funny situation, but despite that, Dutch campaign makers tried to reduce SES differences in smoking by using entertainment.ikweddatikhetkan

A Dutch television show was created in 2008 that used entertainment-education to stimulate smoking cessation among low and moderate educated groups. The show was called ‘I bet I can do it!’ (in Dutch: ‘Ik wed dat ik het kan!’) and showed people doing bizarre and spectacular bets to win money. Additionally, the program followed five groups of smokers who tried to quit smoking. There was a group of road construction employees, bar visitors, posh women, blood bank collegues, and famous Dutch people. The first four groups maintained quit for the duration of the show (seven weekly episodes). Unfortunately, only one of the famous Dutch people maintained quit during the show.

In a paper published this week in a Dutch language journal*, we reported our evaluation of the reach and effectiveness of the tv show among low, moderate, and high educated smokers. With data from the ITC Netherlands Survey (one survey wave before and one after the show aired), we found that 14% of low, 18% of moderate, and 11% of high educated smokers had seen the smoking cessation component of the tv show. Moderate educated smokers who had seen it were more likely to try to quit smoking after the show had been aired. This was not found for low and high educated smokers.

In sum, Dutch campaign makers aimed to stimulate smoking cessation among low and moderate educated smokers by using entertainment. Their tv show succeeded in reaching and affecting moderate educated smokers more than high educated smokers. Although this is a nice success, the entertainment-education strategy for smoking cessation tv shows should be further refined. This can possibly lead to a show that has positive effects on smoking cessation among moderate ánd low educated smokers.

* Nagelhout, G. E., Wiebing, M. A., Van den Putte, B., De Vries, H., Crone, M., Bot, S. M., & Willemsen, M. C. (2014). ‘Ik wed dat ik het kan!’ – Bereik en effect van een televisieprogramma over stoppen met roken bij laag-, middelbaar en hoogopgeleide rokers [‘I bet I can do it!’ – Reach and effectiveness of a television show about smoking cessation among low, moderate and high educated smokers]. Tijdschrift voor Gezondheidswetenschappen, 92, 88-96.

The Dutch expert centre on tobacco control STIVORO has been discontinued from January 2014, a result of several decisions made by the Dutch government and other funders.

STIVORO was founded in 1974 by the Dutch Cancer Society, Lung Fund and Heart Foundation. From 1991, the Dutch Ministry of Health also provided yearly grants to the organisation. STIVORO became known for large mass media campaigns, a strong scientific basis of continuous monitoring studies, smoking cessation courses and operating the national quit line.

Since 2010, STIVORO had already been forced to reduce from a full time operation with the equivalent of 38 full time staff in 2010, to just six in 2013. In 2010, the ministry of health decided to stop all smoking education mass-media campaigns, as well as direct funding for the quit line. In 2011, the ministry further reduced funding for public health information about smoking, and transferred the remaining amount from STIVORO to the Trimbos Institute, the national centre of expertise on mental health and addiction. The ministry wanted a comprehensive lifestyle approach, and opted for the integration of tobacco with other addictions.

Apart from the government decisions, in 2010 the Dutch Cancer Society, Lung Fund and Heart Foundation announced investment in a new approach to tobacco control and that therefore they would withdraw their funding for STIVORO from 2014. Throughout 2013, the remaining small team of STIVORO focussed on continuing to build the knowledge base of policy measures and tobacco industry tactics.

Because the original individual founders of STIVORO wanted to maintain the expertise and distinct profile of tobacco control within a broader alliance of health organisations, they established the Dutch Alliance for a Smokefree Society. A number of employees from STIVORO have continued their work at this new tobacco control organization ‘Alliantie Nederland Rookvrij!’ (Dutch Alliance for a Smokefree Society).

Currently, 33 Dutch organizations have joined this Alliance and more are expected to follow. With this backing, it is hoped the Alliance will be able to continue the vital work of taking on the tobacco industry and, when needed, the Dutch government.

Published as:
Nagelhout, G. E. & Segaar, D. (2014). Netherlands: Change in tobacco control organisations [News Analysis]. Tobacco Control, 23, 95-96. Online available at http://tobaccocontrol.bmj.com/content/23/2/93.full

Premio Dardos Award

This morning, I found out that I won an award: the Premio Dardos Award. It took me a while to figure this out, because it was posted on the Spanish blog of Esteve Fernández and I don’t understand a word in Spanish. After a while, I found out that the Premio Dardos Award is a virtual award sent as a ‘gift’ from one blogger to another as “recognition for the creativity, effort and dedication” they put into their blog. The award originated in Spain and has been sent from blogger to blogger for several years now.

The rules of the award:Premio Dardos

  1. Link back to the person who nominated you (done above)
  2. Display the award icon (see picture)
  3. Nominate 15 others whose blogs you like (done below)

My 15 nominations are:

TOBACCO CONTROL BLOGS
1. Tobacco Related – Blogs from the Tobacco Control Unit of the Catalan Institute of Oncology. Read for example their post on tobacco industry interference in Spain here. Twitter: @TobaccoRelated and @stvfdz
2. Blog Stanton Glantz – I visited Prof. Glantz at UCSF earlier this year. Now, I read his blogs. For example this one about e-cigarettes and smoke-free laws. Twitter: @ProfGlantz
3. Health Media Collaboratory – I also visited the Health Media Collaboratory at UIC earlier this year. I really like their blogs about social media and health. For example this one on tweeting about quitting smoking. Twitter: @HMCollab
4. Tobacco Research – Updates from the University of Bath’s Tobacco Control Research Blog. Read for example their blog about corporate social responsibility and the tobacco industry here. Twitter: @BathTR
5. BMJ Tobacco Control – Analyses and debates of the latest tobacco control research findings and policy developments. Read for example their blog about lobbying against the EU Tobacco Products Directive. Twitter: @TC_BMJ and @DrBFreeman

RESEARCH BLOGS
6. The Thesis Whisperer – A popular blog among researchers and PhD students around the world. Learn here how to write faster or here how to rock your next conference talk. Twitter: @thesiswhisperer
7. The Research Whisperer – Just like the Thesis Whisperer, but with more money (that’s how they introduce themselves on their blog). Learn here how to chair a conference session or learn here about 3 common writing mistakes. Twitter: @researchwhisper
8. PhD talk – Random thoughts on the process of doing a PhD. Read for example their useful post about 20 tips for surviving your PhD. Twitter: @evalantsoght
9. Impact of Social Sciences – This blog is a hub for anyone interested in maximizing the impact of academic work in the social sciences and other disciplines. Read this great post about whether blogging and tweeting about your research is worth it. Twitter: @LSEImpactBlog and @melissaterras

DUTCH LANGUAGE BLOGS
10. Blog Wanda de Kanter – This pulmonologist from the Netherlands wants to prevent youth from starting smoking by denormalizing tobacco use. Read her Dutch language blog post about the shisha pen here. Twitter: @Wdekanter
11. Blog Marc Willemsen – This professor in tobacco control research from the Netherlands blogs in Dutch about tobacco control. Read for example his post about the end of the Dutch Expert Centre on Tobacco Control STIVORO here. Twitter: @Marc_Willemsen
12. Longfonds Blog – The Dutch Lung Fund blogs about healthy lungs and sometimes about tobacco control. Read for example the Dutch language post from the Director Michael Rutgers about the lack of tobacco tax increases in the Netherlands. Twitter: @Longfonds and @MichaelRutgers
13. Blog Michel Rudolphie – The Director of the Dutch Cancer Society blogs about cancer prevention and tobacco control. In one of his Dutch language posts he explains why campaigning against smoking is also a part of cancer prevention. Twitter: @Rudodo and @skipr
14. Blog IQ Healthcare – IQ Healthcare from the Dutch Radboud University Nijmegen Medical Centre was my first employer. Current employees are blogging in Dutch about patients and health care. Read for example this blog about how to make health care healthy again. Twitter: @IQhealthcare and @GertWestert
15. Wie Helpt de Dokter – Dutch language blog with very practical tips for doctors (but also very useful for others). Read for example how to delete apps from your iPhone and iPad here or how to use RSS feeds here. Twitter: @Wiehelptdokter

If you are one of the nominees: Don’t feel obligated to post about it on your blog. Only do so if you feel like it.

If you know other great blogs: Let us all know in the comments below.

And now it’s time to read the 15 blogs that I just recommended to you. Enjoy!

My work visit in the US has almost come to an end. Yesterday was my last presentation about tobacco control in the Netherland at the Arnold School of Public Health of the University of South Carolina in Columbia.

During my presentation I told them about our current Minister of Health, Edith Schippers. She is not like any other Minister of Health. She is not really impressed by the Framework Convention on Tobacco Control, nor by recommendations from the European Union or the World Health Organization. The quotes below illustrate that well:

“We are politicians. We are no technocrats who say: this is a list of things that work best, so this is what we automatically do. Then you could just as well put a computer here.” (Dutch quote here)

“The government thinks it is important that, ultimately, decisions are made at the national political level in consultation with the parliament. We do not delegate this freedom to the European Union, nor to the WHO.” (Dutch quote here)

And her actions in tobacco ‘control’ are even worse. She reversed the smoke-free law in small bars without employees, she stopped funding for all mass media health education campaigns, and she reversed the reimbursement policy for smoking cessation aids.

When I had told the people in Columbia about all this during my presentation, they came with an interesting suggestion. Why not make it obligatory for a Minister of Health to have formal training in public health or medicine? Our current Minister of Health has a Master’s degree in political studies, which doesn’t seem like the right education for being a Minister of Health.

I did some internet research and found out that our last Minister of Health that had an appropriate education for the job was Els Borst. She was a Minister of Health from 1994 until 2002 and has a PhD in medicine. The difference between her and others at the post is crystal clear. She was responsible for implementing an advertising and promotion ban, the smoke-free workplace law, smoke-free public transport, a minimum age limit for buying tobacco, and health warnings on cigarette packages. Prof. Willemsen described the times when she was a Minister of Health as a ‘victory for health’, while he described the years before as ‘happy tobacco industry years’ in his presentation about the history of tobacco control in the Netherlands at an international symposium in Maastricht last year. He concludes his presentation by saying that a strong Minister of Health is the key.

Other interesting suggestions that I got from the researchers in Columbia about what the Netherlands should do about tobacco:

  • Find an alternative where people can work who are currently working for the tobacco industry, to ensure that there is no economic gap when you fight the tobacco industry.
  • Get the word out about what the government should do and is not doing in tobacco control and about the lies of the tobacco industry. Use research findings that people can understand. And expose the lack of efforts by the government at the international level by shaming them.
  • Prevent that young people start smoking by banning all advertising, including in supermarkets, enforcing the minimum age for buying tobacco, and banning vending machines.

This is the final part of my blog series ‘What the Netherlands should do about tobacco’. You can find the other 5 blogs here.

Top 5 cigarette-exporting countriesWhen I present about tobacco control in the Netherlands, I always start by explaining that the Netherlands is the second-largest cigarette exporting country in the world. Many people are surprised to hear that, including the researchers at the Medical University of South Carolina (MUSC) in Charleston whom I visited last Friday. I also told them about how the smoke-free bar law and the reimbursement policy for smoking cessation support were implemented in the Netherlands, then (partly) reversed, and then implemented again. And that the Ministry of health is no longer funding health education campaigns. After telling them all about our recent struggles, setbacks, and successes in tobacco control, I asked them whether they had any recommendations for tobacco control in the Netherlands.

MUSCThe people at MUSC were really concerned about the reversal of tobacco control policies in the Netherlands. Even though policies are (planned to be) implemented again, all the changes make things unclear and that doesn’t help with creating public support and changing social norms. They thought that having a tobacco factory in our country is the main cause of our problems. The tobacco industry is probably influencing our government policy and they have the power to do that because they are a major employer in the Netherlands.

While the Netherlands desperately needs campaigns about the health risks of smoking (such as the recent Tips campaign in the US), the Dutch government isn’t financing them. Communication about the health risks of smoking will be done with the new graphic warning labels that the European Union is going to implement, but something is needed to complement that. The researchers at MUSC came with the idea of offering lung cancer screening to high risk individuals. This can be paid with money from tobacco taxes. A public awareness campaign about lung cancer screening is automatically a campaign about the health risks of smoking. And the nicest thing about this idea is that it would be hard for the tobacco industry to argue against it.

DSCN0891Besides communicating about the risks of smoking, smokers should be stimulated to quit. Or at least, they should quit smoking combustible tobacco. The people at MUSC thought that it may not be a big problem if people switched to reduced-harm products such as smoke-less tobacco, e-cigarettes, or nicotine replacement therapy. Therefore, these products should be made more available. Nicotine replacement therapy, for example, should be sold in smaller packs and should be reimbursed regardless of smokers’ willingness to participate in counseling. Although combining pharmacological therapy with counseling is more effective, smokers who only want to do one of the two should not be discouraged, according to the advices I got from the researchers in Charleston.

If you want to read more advice about what the Netherlands should do about tobacco according to researchers from the US, read my previous blogs about my visits to San Diego, Scottsdale, San Francisco, and Chicago. If you have advice yourself, please do not hesitate to leave a comment below.

IHRPLast Monday I was a guest at the Institute for Health Research and Policy (IHRP) of the University of Illinois at Chicago. During a team meeting of researchers of the IHRP, I presented about tobacco control in the Netherlands and about the findings of my research. At the end of the presentation, I asked the group whether they had any recommendations for tobacco control in the Netherlands. Their message was clear: people are motivated by money, keep that in mind when pushing for stronger tobacco control policies.

They told me about the most important move in tobacco control in the US: the legal challenges against the tobacco industry. After legal challenges in the US, an accord was reached with the major tobacco companies in 1998 (known as the Master Settlement Agreement). The tobacco companies had to pay billions of dollars to compensate for the money that has been spent on tobacco-related diseases, new tobacco control regulations were implemented, and previously secret industry documents were made public. It could help the Netherlands enormously if they sued the tobacco industry and won. Although it is a good thing that a Dutch organization is considering to sue the government for not adhering to an international tobacco treaty, it would be even better to sue the tobacco industry. They are the cause of the problem and they have the money to solve it.

There is evidence that Dutch politicians have connections with the tobacco industry. The people at IHRP acknowledged that it is important that these connections are being exposed in the Netherlands. A necessary next step would be to find out whether politicians are actually taking money from the tobacco industry. Exposing that could have an even larger impact on public opinion.

Other suggestions to motivate people with money were the following:
– Raise taxes for all tobacco products (including cigars and roll-your-own tobacco). Even if there is border crossing for cheaper cigarettes in neighboring countries, higher taxes will still decrease smoking consumption and increase government revenue.
– Reimburse health professionals for helping patients to stop smoking and tell them how they should do this.
– Stimulate private employers to financially incentivize their employees for quitting smoking. This saves both the employers and the employees money. Despite the incentives that employers have to pay, they will still save money because non-smoking employees are less often sick.

The lesson I learned on my visit to Chicago is that although we are motivated to have stronger tobacco control policies because of public health reasons, we can still achieve this by going after the money.

Which researcher doesn’t know them: the co-authors (or supervisors) who don’t have time to read your paper. It’s a difficult issue that every researcher experiences at least ones. Do you keep sending reminder emails with your paper attached or do you give up after a while? And what do you do eventually: do you publish the paper without them as a co-author? Do you publish it with them as a co-author even though they didn’t read the paper? Or do you give up on your work altogether and never publish it? I asked it some researchers in a small survey. Read their tips, strategies and revelations here.

For this blog, I draw from my own experience of working with many co-authors ánd from a small social media survey (n = 20) that I performed via Twitter, Facebook and LinkedIn earlier this month. Most respondents were PhD students (65%, n = 13) and the rest of the sample consisted of post-docs (15%, n = 3), senior researchers (10%, n = 2), and assistant professors (10%, n = 2). Respondents completed the survey online and remain anonomous.

Deadlines and cliffhangers

You have written a draft research paper or report and you want someone else to look at it. Perhaps they are your supervisor or a collegue or expert who you want to be a co-author of your work. What do you do to make sure that these persons respond to your request to read your work?
The number one answer in my social media survey was ‘I give them a deadline’ (65%, n = 13). Although you may not need everyone’s responses within three weeks, say in your email that you do. I try not to ask people to respond within one week, unless it is really urgent. It’s probably better to give people two to four weeks if you’re asking them to comment on a full length research paper. Also, ask people to let you know when they need more time.

Other top answers were ‘I call them or ask them face-to-face when they have time’ (35%, n = 7) and ‘I spend some time writing a good email in which I make him/her curious about my work’ (35%, n = 7). Writing a good email that makes people curious can be very powerful. If you write an email in which you only say that you would like people’s comments on your paper before a certain date, your request will either be forgotten or added to the bottom of their to-do list. You can also write an email with something like “In my paper, I have examined the impact of X on Y. I think this has never been done before. The results are quite surprising (see the attachment).” Curiousity will take over and people open your attachment immediately. If you’re lucky, they will also respond immediately.

Other strategies that were mentioned in the survey: sending lots of reminders (15%, n = 3) and writing an email with his/her secretary or a respected collegue in the CC (15%, n = 3). Some respondents are very lucky, they responded that they don’t have to do any of this, because people always respond quickly to their requests (15%, n = 3).

Difficult decisions

You have used all the strategies outlined above, but the co-author stil does not respond to your request to read your work. What do you do? I was glad to see that nobody in the survey answered that they would give up and never publish their work. Most people opted to call or ask face-to-face when the co-author has time (60%, n = 13). Others just keep sending emails and reminders until they get a response (30%, n = 6). It probably depends on whether you are asking a co-worker or an external party that you don’t know well and never meet face-to-face.

Sometimes, you have to make more difficult decisions. You may want to decide to publish your work without the co-author who doesn’t respond. Some of the respondents of the survey answered that they would do that (25%, n = 5). A few respondents revealed that they sometimes publish something with a co-author who didn’t read the paper (15%, n = 3). Two of them added an explanation: (1) a co-author who doesn’t read a draft before submission usually does help with the revision of the paper; and (2) sometimes you don’t have a choice because of a project rule about co-authorship, but it is not a nice decision. Although it’s great that nobody in the survey gave up on their work, it is not a good thing that people sometimes feel forced to include co-authors who do not qualify for a co-authorship. PhD supervisors and academic writing courses should discuss this with their students and not let them make these difficult decisions alone.

Thanks very much to the 20 respondents of my small survey! Of course this survey is not representative for the entire research community. Therefore, I invite all readers to comment below. Please let us know how you deal with these issues and what you think of the strategies described in this blog.

In countries such as Canada and Australia, smoking is no longer seen as a mainstream or normal activity in our society; it has been ‘denormalized’. Anti-smoking campaigns and smoke-free laws may have contributed to the reduction in social acceptability of smoking in these countries. We recently published a paper in which we examined the same thing for France, the Netherlands and Germany. One of the most striking findings for us was that less than 60% of Dutch smokers agreed that society disapproves of smoking, compared to about 70% in France and Germany, about 80% in the United States, the United Kingdom and Australia, and almost 90% in Canada. It seems that social denormalization of smoking is urgently needed in the Netherlands.

Our study showed that one aspect of the social acceptability of smoking influenced whether smokers attempt to quit smoking. This aspect was whether people who are important for the smoker believe that they should not smoke. Thus it seems that tobacco control advocates should focus on changing the perception of disapproval of important people in smokers´ environments. When smokers think that people who are important to them believe that they should not smoke, they are more likely to attempt to quit smoking.

An important question remains: How can we change the ´important people disapproval´? Findings from our study suggested that the warning labels on cigarette packages, anti-tobacco information campaigns and smoking restrictions in France, the Netherlands and Germany in the period 2006-2008 have not succeeded in changing this aspect of the social acceptability of smoking. I personally think that campaigns with a social media component may be promising to specifically change the perception of disapproval of important people.

A Dutch mass media campaign with social media component that started in 2012 seems to be a candidate for changing the important people disapproval. The campaign ‘roken is zóóó’ (translation: ‘smoking is sóóó’) was developed by the Dutch cancer society and lets people share with their social media friends how old-fashioned or strange it is if you still smoke. For example, ‘smoking is sóóó (old-fashioned like) blue mascara’.

'Roken is zooo' campaign

‘Roken is zooo’ campaign

What do you think? Will this campaign decrease the social acceptability of smoking in the Netherlands? Or do you have different ideas? Feel free to leave comments!

In the Netherlands, smoking ban inspectors are facing aggression in bars lately. They have to travel in pairs with police back-up to prevent serious problems. Is this simply caused by a general increase in violence in our society or is something about the Dutch smokefree law making people aggressive? Although I have no scientific proof about this specific question, I think it is useful to at least explore the latter option here. I also propose a solution: a crystal clear smokefree law without exceptions and smoking rooms.

The Netherlands started off with a smokefree law in July 2008 that banned smoking in all hospitality venues, but allowed owners to create designated enclosed smoking rooms. Owners of small bars considered this law unfair, because they could not create a designated smoking room because they lacked space to do so. Helped by the tobacco industry, they expressed their anger with protests, overt non-compliance, and lawsuits. In July 2009, the enforcement of the smokefree law for small bars was temporarily suspended pending the lawsuits. In February 2010, it was decided by the High Court that the smokefree law should apply to all bars again. However, a newly instated Minister of Health decided to change the smokefree law so that it did not apply to small bars anymore since July 2011. Finally, political changes at the end of 2012 triggered a parliamentary voting resulting in the decision to reinstate the smokefree law for all bars as of July 2014.

Currently, the Dutch smokefree law thus includes exceptions and the possibility to create smoking rooms. Although this is probably confusing enough in and of itself, the law has also been changed numerous times. I can imagine that this causes confusion and this may cause some bar owners or visitors to become aggressive. Of course, I am not condoning aggressive behavior (!), but I do think that the aggression that smoking ban inspectors face may have been caused by unclear legislation.

Luckily, there is a simple solution to all this. Make the smokefree law crystal clear: no smoking at all inside any workplace or public place, not even in a small bar or in a smoking room. This solution improves the health of bar owners and visitors by decreasing exposure to second-hand smoke and possibly also by decreasing aggression due to increased understanding. Even bar workers and visitors who do not enter smoking rooms will benefit, because smoke is known to leak out of smoking rooms. Of course, the ban on smoking rooms should be implemented no later than July 2014, when the reinstatement of the smokefree law for all bars was planned anyway. Finally, it is important to educate the public about the harms of second-hand smoke, so that smokers understand why it is important to take their smoke outside.

The Dutch tobacco industry sounded the alarm last month. They claim that there is so much cross-border cigarette shopping in Belgium that the Dutch tobacco companies, gas service stations, and the Dutch State lose millions of Euros. Although this may be true, their solution is an interesting one. The tobacco industry proposes to lower Dutch cigarette taxes in order to lower the price difference between Belgium and the Netherlands and tackle the cross-border shopping issue. Why would the tobacco industry not propose to increase the cigarette taxes in Belgium or why don’t they increase the prices of cigarettes in Belgium themselves? The answer is obvious: they are not concerned with cross-border cigarette shopping, their only concern is to keep people addicted to cigarettes so that they can make more money. Lower cigarette prices will do just that.

It happens to be that I just analyzed the issue of cross-border cigarette shopping in Europe in a scientific paper that was published this week (open access available here). My analyses showed that cross-border cigarette shopping is indeed more common in regions bordering countries where cigarette prices are considerably lower (for example the German border with Poland). In the Netherlands, however, only 2% of smokers reported that they frequently bought cigarettes outside their country in the last six months. So it seems that cross-border shopping is not a big issue in the Netherlands, but it should be noted that these data are from 2008 and that there have been cigarette tax increases in the Netherlands since that time. The latest data on cross-border cigarette shopping are available here in a Dutch fact sheet. These data show that less than 5% of Dutch smokers bought their last package of cigarettes in another European country (mostly Belgium) in 2012.

The question is: should Dutch cigarette taxes be lowered or should Belgian cigarette taxes be increased? If the only problem would be the issue of cross-border cigarette shopping, then both options would be equally good. However, there is clearly more at stake here. Smoking causes death and diseases, and to ultimately increase public health it is important to increase cigarette taxes in Belgium (and other European countries) to the level of the Netherlands. This can motivate smokers from both countries to quit smoking and can prevent that children in both countries start smoking.

Meanwhile, the tobacco industry will keep calling for lower cigarette taxes in the Netherlands. Pretending to be worried about cross-border cigarette shopping, but actually desperately looking for young replacement smokers for all those who die from tobacco-related diseases.

By any measure, Dutch tobacco control has been through difficult times in recent years. The government coalition that came to power in 2010 cut all government funding for health education campaigns, stopped funding for the national tobacco control centre STIVORO, and weakened or reversed existing tobacco control policies. However, since the end of 2012, there is a new government coalition and it seems that the political climate for tobacco control is slowly improving.

From October 2010 until November 2012, a minority coalition between the conservative-liberal party VVD (People’s Party for Freedom and Democracy) and the Christian democratic party was in power, with support from the populist Freedom Party. The first act of the newly instated Minister of Health Schippers (VVD) was to partially reverse the smoke-free law, allowing smoking in bars of less than 70 m2 without employees. Following this decision, compliance with the law also decreased in bars that were not exempted, because the risk of getting fined is small.

Since November 2012, the Netherlands has a government coalition between the VVD and the labour party (PvdA). Unlike the previous coalition, the VVD and PvdA coalition did not contain predetermined agreements about reversing tobacco control. Furthermore, tobacco control is no longer the responsibility of the minister of health, but is now under the deputy minister of Health Van Rijn from PvdA. Moreover, there is now a small majority in parliament that wants to have stronger tobacco control policies. This situation has been used by a MP to call for a vote on the exemption to the smoke-free law for small bars. On 12 February 2013, a small majority voted for a reinstatement of the smokefree law for all bars. After a short period in which it was unclear whether this recommendation from parliament would be followed, on 27 February it was confirmed that the government is going to implement the stronger law- however the time frame is unclear. Meanwhile, a court case was brought by the Dutch grassroots organisation Clean Air Nederland against the state. On March 26, the court ruled that the Netherlands has violated the FCTC by allowing smoking in small bars, and that all bars should immediately be made smoke-free.

Although the stronger smoke-free law was heralded by health organisations as a major victory for tobacco control, it remains to be seen whether the new law will work better than the previous law. Compliance was already a problem before the law was partially reversed, with an estimated 20-30% of all bars not complying with the ban from the start. The proposed stronger law might not resolve this issue, because it is still not a comprehensive ban as it allows hospitality venues to have designated smoking rooms. Also, smokers’ support for the smoke-free law is still relatively low, likely due to a weak communication strategy which failed to explain the harms of secondhand smoke. It is important that the government educates the Dutch public to generate support for implementation.

While Dutch tobacco control still has a long way to go, it is slowly again moving in the right direction.

Published as:
Nagelhout, G. E. & Willemsen, M. C. (2013). The Netherlands: Tobacco control atmosphere improving [News Analysis]. Tobacco Control, 22, 181. Online available at http://tobaccocontrol.bmj.com/content/22/3/180.full

It is quite common for a researcher to spend some time working in another country. A lot of PhD programs stimulate students to get international experience and help them with finding funding. International experience boosts your CV, it helps you to get jobs and grants. So why is that? I found out for myself.

Normally, I live and work in the Netherlands, where I study tobacco control, social norms and smoke-free laws. Since January of this year, I have been working at the Moores Cancer Center of the University of California San Diego. California is the place to be when you’re interested in the social norms approach for tobacco control, so the choice was easy. But – to be totally honest – I decided to do this work visit mainly because I wanted to have the international experience for my CV. I already had a quite large international network that comes with working on an international project and I attend international conferences at least once a year. I did not really think that working abroad would add much to that experience, except that it would look good on my CV. Luckily, I was wrong and I learned a lot from working in the United States!

A new research environment
Let’s skip the obvious part of why you should have international experience. Of course it is good for your international network, your CV and possibly your language skills. However, the most important learning experience of my international work visit was to work in a research environment that was very different from what I had experienced before. Even though I’m used to working with a lot of co-authors from different institutions and countries, it is totally different when you are actually working at another institution in another country where your regular supervisors are not around. You get to know other academic perspectives than the ones that you are so familiar with, which helps you to find out which academic perspective you yourself (want to) have.

Learning about your own country
Perhaps you wouldn’t expect this, but my work visit abroad learned me a lot about my own country. If only because people would ask me tons of questions about the Netherlands that I had to look up myself before I could answer them. I have also presented a couple of times about tobacco control in the Netherlands. When preparing my presentation, I first had to read more about the history of tobacco control in the Netherlands, because I realized that I didn’t know enough of that to present about it. During questions and answers and discussion after my presentations, I got a real good sense of the differences and similarities between the Netherlands and the United States. You literally learn to look at your own country from a distance, which makes you understand it better.

Get inspired
The main goal of my international work visit was to write papers about population support for smoke-free laws. Another thing that I was hoping to achieve, was getting inspiration about what kind of research I wanted to do next. So I decided to make the most of my visit and not only visit the Moores Cancer Center, but also the Mayo Clinic in Scottsdale, the Center for Tobacco Control Research and Education in San Francisco and the Americans for Nonsmokers’ Rights in Berkely. I met some great people there that all advised me about what kind of research would be good for my career and for tobacco control in the Netherlands. This was really helpful for me and I owe them many thanks.

Personal skills
Last but certainly not least, you will develop personal skills by being in another country on your own. You have to adapt and be flexible and you will get more independent. You might even overcome some of your personal fears! For example, I used to be afraid about driving in very busy traffic or to places I was unfamiliar with and I mostly avoided driving altogether. However, in the US I couldn’t avoid driving and I had to do it each and every day. Now, I am pretty comfortable with driving and I would probably have never gotten at that point when I wasn’t ‘forced’ to do it because I was on my own.

In sum, every researcher should try to spend some time working in another country. It is not only very good for your CV, but also a lot of fun. It’s like a colleague of mine wrote about her experience working abroad: ‘Variety is the spice of life‘.

World-Travel-HD-Wallpaper

One month ago, I presented the story about tobacco control in the Netherlands for tobacco control researchers in San Diego. During my talk, I focused on the most peculiar part of the story: the period in which tobacco control policies were being reversed instead of strengthened and Dutch tobacco control was going backwards. Last week, I planned to give the same talk to tobacco control researchers in San Francisco. When I prepared my talk, I realized that I had to change the ending. In the last couple of weeks it became clear that the climate for tobacco control is improving in the Netherlands. One important example is that a majority of Dutch parliament voted for a reinstatement of the smoke-free law for all bars.

The people in San Francisco, however, warned me that for successful policy it is not enough to have political support. Public support may be even more important. I asked them what we should do in the Netherlands to get more public support, because we know from country comparative studies that the Dutch population is less supportive of tobacco control than people from other countries. Their answer was simple: to get public support for tobacco control policies, you need to denormalize smoking. Based on the experience of California, they often recommend countries to denormalize smoking by increasing awareness of the harms of second-hand smoking and by increasing awareness of tobacco industry manipulation. But after hearing about the low levels of awareness of the harms of smoking in the Netherlands ánd the low levels of physician advice to stop smoking, the people in San Francisco wondered whether more “retro” approaches may be needed in the Netherlands first. It seems that Dutch health professionals need to be better educated about the harms of smoking. They need to be told that the most important thing that they can do for their smoking patients is to tell them about the risks of smoking and to advise them to quit smoking.

An opportunity that cannot be missed is the reinstatement of the Dutch smoke-free hospitality industry law, which ensures that the exemption to the law for small bars will be reversed. This opportunity should be taken to lobby for a 100% comprehensive law without smoking rooms. A policy without smoking rooms is important because it is much more clear, which will increase compliance. Smoking rooms are propagated by the tobacco industry, because it helps them to link the smoking ban with economical damage and competitive disadvantage for bars that are too small to have a smoking room. Air quality measurements can be helpful in the lobby process for a 100% smoke-free law, because they demonstrate that smoke leaks out of smoking rooms which exposes the public outside the smoking room to second-hand smoke.

Another issue with the Dutch smoke-free law is compliance. The people in San Francisco told me that the government can ensure compliance with the new law by immediately acting in a very public way when bars violate the law. But, as said before, it is extremely helpful when the public supports the law. Therefore, the Netherlands should educate the public about the harms of second-hand smoke. And when the government (again) decides to not take on this important task, others have to take that responsibility. It doesn’t have to be a flashy, expensive campaign, it just needs to explain why protection from exposure to tobacco smoke is a deadly serious business.

Last week, I visited tobacco control researchers in Scottsdale, Arizona. They told me about some of the great initiatives in tobacco control in Arizona and I told them about recent developments in tobacco control in the Netherlands. After explaining about the current situation for tobacco control in the Netherlands, I asked them the question: What should the Netherlands do about tobacco?

The Netherlands can learn a lot from tobacco control in Arizona. Arizona was the first state to restrict smoking in several public places and they now have comprehensive smoke-free laws in workplaces, restaurants, bars and gambling venues. Also, they had some very innovative counter-marketing media campaigns in the past. For example, the ‘Tumor Causing, Teeth Staining, Smelly Puking Habit’ campaign that both denormalized smoking and explained about the dangers of smoking and second-hand smoking in a way that is appealing to youth.

Clearly, the Dutch government has not been doing what they should do to decrease tobacco use in the Netherlands. However, I was told in Scottsdale, Dutch tobacco control advocates seem to be doing all the things they can and should do. Advocacy, activism and raising public awareness is what matters. The tobacco control researchers in Scottsdale were very impressed by the Dutch FCTC shadow report and the way it was presented it to the media: the report was publicly handed over to an actress impersonating the Dutch Minister of Health. They think that having actors impersonate public figures can be very powerful, which has been shown again and again by US television shows.

One important thing that we could still work on in the Netherlands is communicating about the costs of smoking. This will make the politicians and the average person pay attention. A small chance of getting cancer in the far away future is less tangible than the money that is lost to smoking. Specific calculations about what the average person pays from their tax money because certain tobacco control policies are not being (fully) implemented are very helpful. Therefore, getting some health economists on board may help to improve tobacco control in the Netherlands.

Today, I presented what I call “the peculiar story of tobacco control in the Netherlands” for tobacco control researchers in San Diego, California. I talked about the crazy things that are going on in the Netherlands where effective policies are being reversed, government funding for the world-renowned national centre on tobacco control STIVORO stopped, and tobacco control is going backwards. After explaining our story, I asked them one simple question: What should the Netherlands do about tobacco?

I got lots of suggestions; some more realistic than others (e.g. become Minister of Health). The bottom line of all suggestions being that the Netherlands needs to denormalize smoking. Results from the International Tobacco Control Policy Evaluation Project (or ITC Project) have shown that only 22% of smokers in the Netherlands, the lowest figure in 16 countries, have a negative opinion of smoking. In the Netherlands, we have always experienced this as a very shocking and depressing finding, but I was told today that there is a positive side to this. It means we have much room for improvement!

My colleagues in San Diego told me that you cannot change norms about smoking without educational campaigns. They advise to campaign about the harms of smoking and second-hand smoking and the tactics of the tobacco industry. Focus on adults not youth and on non-smokers instead of smokers, they said. If a paid media campaign is not feasible, try an earned media campaign. For example, by getting a celebrity who’s suffering from a tobacco related illness to speak up about this issue.

Other thoughts were that you need the government to help you with tobacco control. They should orchestrate. Getting the government to do that may require a focus on return on investment. Show the productivity loss from smoking and that smoke-free laws do not have a negative impact on the economy. Convince them by using economic arguments.

Within the next couple of weeks, I will also present the story of tobacco control in the Netherlands in other places in California and I will ask the same question there. So stay tuned for part 2 of ‘What the Netherlands should do about tobacco’.

The Dutch smoke-free law in the hospitality industry is almost five years old. Like human five-year olds, smoke-free laws who are five years old start to evaluate their position within their environment. They become a bit more compassionate and social and they realize that they are not alone in this world and that others may need Child development stagesprotection. What I’m referring to is the news last weekend that we may get a stronger smoke-free law in the Netherlands soon. I had imagined that the Netherlands would be one of the first countries with a smoke-free law that was in place for five years and was still not working. But maybe I was too pessimistic and the exemption for small bars without employees will be reversed before July, when the Dutch smoking ban in the hospitality industry celebrates it’s fifth anniversary.

I’m no pessimist and that’s why I named my PhD thesis on the Dutch smoke-free law “It has been done elsewhere, it can be done everywhere” (which is a quote from the Smoke Free Partnership). So I always believed that we would get a comprehensive smoke-free law in the Netherlands eventually. But I think I’m being realistic when I say that I don’t believe we will get a truly comprehensive smoke-free law in the Netherlands before the law turns five. The reason being that reversing the exemption to the law for small bars will not make our ban truly comprehensive. More is needed.

Before the exemption to our smoke-free law was in place, compliance with the law was already lacking. This isn’t surprising, because the law was implemented without adhering to the recommendations from the World Health Organisation (WHO). The WHO recommends to implement a 100% comprehensive ban without smoking rooms or exceptions, to ensure strong enforcement and to run an educational campaign about the harm of second-hand smoke. These things were not done in the Netherlands. It’s great that the exemption for small bars will probably stop soon, but the smoking rooms need to go too, and there has to come a good campaign that explains why a smoke-free law is needed. Scientific evidence has established a long time ago that second-hand smoke heightens the risk for lung cancer, heart diseases and respiratory diseases, but many people in the Netherlands are still unaware.

When I started my PhD project on smoke-free laws, I developed the habit of photographing smoking ban signs whenever I was abroad. Still, I cannot resist the urge to grab my camera when I see a ‘nice’ smoking ban sign. Most of these pictures are made in Europe, where smoking ban signs are for indoor public places only and where signs only explain that smoking is prohibited without explaining why. I am now for the first time in the United States for a temporary working visit at the University of California San Diego. After one week in California, I have literally seen more smoking ban signs than smokers.

Outdoor smoking ban signs (San Diego, California)

Outdoor smoking ban signs (San Diego, California)

Of course I knew beforehand that there would be a larger number of smoking ban signs and a lower number of smokers in California than in Europe. Also, I knew smoking is banned in a lot of outdoor areas in California, such as beaches, parks and outdoor seating areas of bars and restaurants. What I did not expect was that some signs explicitly explain why smoking is prohibited. In my hotel, signs state that although there are designated smoking areas (outside), tobacco smoke is known to cause cancer in the state of California. Another sign that I encountered today warned that the outside air contains chemicals, including tobacco smoke, known to cause cancer and birth defects or other reproductive harm. Although the health rational for banning smoking outdoors is controversial, it is important to communicate about the harms of (second-hand) smoking and smoking ban signs seem to be a very suitable outlet.

Smoking ban signs with health rationale (San Diego, California)

Smoking ban signs with health rationale (San Diego, California)

Explaining the health rational for smoke-free laws is important to stimulate public support for smoke-free laws. Public support for smoke-free laws facilitates the adoption of legislation, ensures compliance with smoke-free laws, triggers the implementation of voluntary home smoking bans, and stimulates smoking cessation. Stimulating public support for smoke-free laws by explaining why smoke-free laws are important fits within the social norms approach in tobacco control. The state of California pioneered in using this social norms approach to reduce tobacco consumption by reducing the social acceptability of smoking.

In the Netherlands, public support for smoke-free laws is relatively low compared to other countries and smoking is still socially acceptable. We have much to learn from experiences with tobacco control in California and that’s why I came to San Diego! I hope to learn lots here and will keep you all posted on my experiences and work.

This week, the Dutch Food and Consumer Safety Authority announced with a press release that the number of bars that are smoke-free increased slightly since this spring. The percentage of Dutch bars without smokers increased from 51% to 57%. Much to my surprise, some important Dutch news agencies interpreted this as good news: more bars observe the smoking ban. However, it doesn’t seem to me that a change from 51% to 57% is very relevant (even if it is statistically significant, which does not seem to be reported anywhere). Moreover, we are talking about bars that are not exempted from the smoke-free legislation, so compliance should be 100%.

Let’s look at the bigger picture here. The trend in compliance since the year 2008, when the smoke-free hospitality industry legislation was implemented in the Netherlands. In the figure below, you can see that compliance with the smoking ban was never 100% in Dutch bars and discos. However, things really changed in the autumn of 2010 when a new government coalition agreement was published which stated that small bars without employees would be exempted from the smoking ban. Compliance decreased from 72% to 49%. Officially, the exemption became law in July 2011, but there were no inspections anymore in small bars without employees since the end of 2010. When looking at this longer trend, no one in their right mind would conclude that things are getting better in Dutch bars.

Source: Voedsel en Waren Autoriteit en Intraval. Inventarisaties naleefniveau rookvrije horeca.

Source: Voedsel en Waren Autoriteit en Intraval. Inventarisaties naleefniveau rookvrije horeca.

 

In the spring of 2011, the reporting of results changed from all bars and discos to separate compliance figures for discos, bars that are not exempted from the smoking ban, and bars that are exempted. Even if you only look at the numbers since the spring of 2011, you see clearly that there is a slight fluctuation in compliance and that there is certainly not enough evidence for an increasing trend.

My conclusion: the exemption to the smoking ban for small bars without employees has created confusion and controversy. As a consequence, a large number of bars that are not exempted from the ban do not comply with the ban. The time has come to admit that the partial smoking ban in the Netherlands is not working and to implement a comprehensive ban.

It began a couple of weeks before my PhD defence was scheduled. Almost everyone would tell me: “Good luck with the preparations!” And when I told someone that I was going on on a short vacation two weeks before my defence, they would ask: “But don’t you need to prepare for your defence?” All this talk about ‘the preparations’ made me feel insecure, and I’m probably not the only one. I couldn’t really think of any preparations for my PhD defence that would take up several weeks of time. And I can tell you now that you don’t need to prepare for several weeks, because there are only three things you should do and you can do them in three days.

1) Read your PhD thesis

In the Netherlands, you finish and publish your PhD thesis several months before your defence. During your defence, you get questions about your thesis only. It is not an examination about other topics. Therefore, the main thing that you should do to prepare for your (Dutch) PhD defence, is reading your thesis from beginning to end. Do this one or two weeks before your defence, so you still remember most things you wrote.

2) Practice your defence

Practicing your PhD defence with the help of some colleagues is very useful. Let your colleagues pretend that they are in the examination commission and let them ask you questions about different parts of your thesis. Ask for feedback at the end of the practice and try to use this feedback when you are doing your real defence.

3) Practice your presentation

A PhD defence in the Netherlands is a public event. At most universities, you get about 15 minutes to present your PhD research to the public. You can’t really prepare for the questions that are asked after the presentation (because you don’t know what the commission will ask you), but you can prepare your presentation. Practice with some public -for example during the practice of your defence- and ask for feedback. Then process the feedback in a new version of your presentation and practice again.

Social media survey

A very small social media survey (n = 11) that I performed this week among Dutch respondents with a PhD confirms that the three things stated above are the things that most of the respondents did to prepare for their defence. Other things that they did were: reading recent literature about their professional field, reading about the people in the examination commission, and preparing questions that the committee might ask. The most useful thing you can do to prepare for your defence, according to this small survey, is practicing your defence.

Done is done

When you have done the three things stated above, decide that your preparations are done and stick with it. Don’t let the good-luck-with-the-preparations people get to you. They mean it well, but there really isn’t so much you can do to prepare for your PhD defence.

Staying informed about your field of work can be time consuming. Fortunately, there are several great internet tools to find out quickly what’s going on in your professional area. Here are my favourite tools.

RSS feeds

You can use RSS feeds when you want to stay up to date about new content on certain websites. For example, I have RSS feeds on new papers in the journals Tobacco Control and Nicotine & Tobacco Research. It is also possible to create RSS feeds for blogs that you want to follow (for example, see the orange RSS feed logo at the upper right corner of this blog). You need to set up a feed reader to read these feeds, for example Google reader. Follow the steps here (English) or here (Dutch) to start using RSS feeds. You can log into the feed reader everywhere, using your desktop computer, laptop, smartphone or tablet.

Google alerts

When you want to stay informed about new online content on a particular topic instead of all new content on a particular website, you can use Google alerts. I use Google alerts to stay up to date about news on the smoke-free law in the Netherlands, regardless of whether the news is featured on a major news website or a small local site. Also, I have an alert for my own name, so I know what people write about me on the internet. An additional benefit is that I know immediately when one of my papers is published online. You can get the alerts into your feed reader (see above) or in your email inbox. Follow the steps here to start using Google alerts.

Twitter

A less efficient but more fun way to stay informed is using Twitter. Follow people who are in your field of work and let them inform you with their tweets. Of course, Twitter is much more than only getting information, it is also about communication, sharing, ideas, advice, education, networking, and more. Therefore, Twitter can take up more of your time than you would want. An efficient way to use Twitter for information is using Twitter lists. For some fields there are existing lists that you can follow. For example, this list of international tobacco control professionals (English) or this list of Dutch tobacco control professionals (Dutch). Find out here how you can create your own list.

Newsletters

Of course you can also get your information from newsletters. Some are available on paper or through email and others can be followed online. If you do not want to be disturbed every time a new email newsletter comes in, you can set up a ‘rule’ that automatically moves the newsletter to a certain folder. Follow the steps here to set up a rule in Outlook. There are also Twitter newsletters, that can be helpful if you want to know what is said on Twitter about a specific topic but don’t want to be on Twitter yourself ór don’t have the time to follow everything on Twitter. For example, this daily newsletter on smoke-free issues or this weekly newsletter on Dutch tobacco control issues (both in English).

And now: YOUR favourite tools

I have performed a small survey on Twitter (n = 5) to find out how others stay informed about their field of work. The most popular tools to stay informed were: Twitter (n = 5), institutional websites (n = 4), newsletters (n = 3), journal websites (n = 2), and LinkedIn (n = 2). Only one respondent reported using RSS feeds and none used Google alerts (you should give them a try, they are my favourites).

I realise that a survey among five people is not that informative and that my sample is highly biased as it consists of my Twitter followers. Therefore, I invite you to comment below and let me know how YOU stay informed. Are there other tools that we should all start using today? Please let us know!

I recently found out that there are quite a few researchers who use the statistical software package SPSS for quantitative analyses but do not use the programming syntax. In the Netherlands, academic statistical training for social sciences does not always include learning to use syntax. The reason probably is that many social scientists in the Netherlands use SPSS and this program allows you to use menus and dialogue boxes without having to learn the syntax. However, using SPSS syntax is easy and it saves you lots of time. I will explain that further below ánd show you the basics.

First and foremost: It saves so much time!

It would be fun if we would never had to run the same analyses repeatedly. However, most of us are not that lucky. Smoking prevalences have to be calculated for your country each year, you have to rerun your analyses after a comment from a co-author or reviewer, and your analyses have to be done all over again when you remember that you forgot to recode one of the variables first. By using syntax, you can rerun your analyses in a flash by hitting the ‘run’ command in the syntax window.

No excuses; it’s easy!

Everybody who can run analyses in SPSS can use syntax. You do not have to learn a programming language. You can just hit ‘paste’ instead of ‘ok’. The paste command puts the code directly into a syntax window which you can ‘run’ (click ‘►’ or type control-R) from there (select which command you want to run by highlighting it with your cursor or clicking on it). After pasting your commands for some time, you will probably learn the language automatically.

More possibilities!

For some analyses, SPSS syntax gives you more options and flexibility than the menus. There are also SPSS syntax macros available on the internet (for example here) that help you run analyses that SPSS cannot otherwise do.

And now: the basics

Open a syntax window by choosing file > new > syntax.
First type an asterisk followed by the date and topic of the syntax, followed by a full stop:
*20121029 Syntax for paper on smoking in the Netherlands in 2011.
This is of course optional, but I think it is useful to save the date and topic of each syntax file. You can also use the asterisk followed by a line of text and ending with a full stop to place comments in your syntax file.

*Run a frequency table of the smoking prevalence by typing.
WEIGHT BY weightfactor.
FREQUENCIES smokingprevalence.
*Or you can also type.
FRE smokingprevalence.
*Typing the first three or four letters of the command is enough.

*Calculate the mean number of cigarettes per day, by typing.
RECODE numberofcigs (99=symis) (else=copy).
MEANS numberofcigs.

*Or recode a variable into another variable.
RECODE numberofcigs (0 thru 5=1) (6 thru 9=2) (10 thru highest=3) INTO cigscategory.
VALUE LABELS cigscategory 1 ‘0-5’ 2 ‘6-9’ 3 ’10 or more’.

*Or make an even more complicated variable.
IF country=1 timetofirstcig=timeNL.
IF country=2 timetofirstcig=timeGE.
IF country=1 numberofcigs=cigsNL.
IF country=2 numerofcigs=cigsGE.
RECODE timetofirstcig (0 thru 5=3) (6 thru 30=2) (31 thru 60=1) (60 thru highest=0).
RECODE numberofcigs (0 thru 10=0) (11 thru 20=1) (21 thru 30=2) (31 thru 98=3) (99=sysmis).
COMPUTE heavinessofsmoking=timetofirstcig+numberofcigs.
VARIABLE LABELS heavinessofsmoking ‘Heaviness of Smoking Index’.

*Run a crosstab by typing.
CROSSTABS smokingprevalence by year.
*Or add more options.
CROSSTABS smokingprevalence by year / cells=column / stat=chi.

*Making selections.
SELECT IF sex=1.
*Or making temporary selections.
TEMP.
SELECT IF sex=1.
*Or filtering.
COMPUTE filtersex1=(sex=1).
FILTER BY filtersex1.
FREQUENCIES smokingprevalence.
FILTER OFF.
*Or using split files.
SORT CASES BY sex.
SPLIT FILE BY sex.
FREQUENCIES smokingprevalence.
SPLIT FILE OFF.

Type ‘EXECUTE.’ and run this command when you want your recodings to be performed immediately. If not, it will be performed before you request output (for example when you run a frequencies command).

Finally, you might want to turn on the option that allows you to see your syntax code in the output file by choosing edit > options > viewer and switching on ‘display commands in the log’.

If you do not know the syntax code of an analyses, use the point-and-click commands and paste the syntax. After pasting, you can adapt the code first or you can run it immediately.

Easy, right?

English powerpoint Public PhD defence presentation Gera Nagelhout (pdf)
Download fulltext PhD thesis Gera Nagelhout (pdf)

 

“I would like to tell you about my PhD research, that is about the impact of smoke-free legislation on smoking.

Smoking tobacco products like cigarettes is very harmful. As can be read on cigarette packages for years now, smoking clogs the arteries, which can cause heart attacks and strokes. On top of that, smoking can lead to a slow and painful death. For example by long diseases and cancer. Moreover, smoking is very harmful for non-smokers who are exposed to second-hand smoke. People who have to do their jobs in the smoke every single day have a heightened risk for lung cancer, heart diseases and respiratory diseases. Infants and children who grow up in the smoke have heightened risk for sudden infant death syndrome, asthma, middle ear infections and meningitis.

The World Health Organisation recommends, therefore, to discourage tobacco use. The most important policy measures are summarised in the acronym MPOWER. Specifically, the World Health Organisation recommends to implement smoke-free legislation in workplaces and public places, to reimburse smoking cessation aids, to run campaigns about the harm of smoking and second-hand smoking, to require health warnings on cigarette packages, to ban marketing of tobacco, and to increase taxes on tobacco.

Immediately after I started my doctoral research, smoke-free hospitality industry legislation was implemented in the Netherlands, an implementation campaign for the smoke-free law started and a smoking cessation campaign by STIVORO, ánd the taxes on tobacco increased. I have evaluated all these policy measures in my PhD thesis, but I have mostly focused on the impact of smoke-free hospitality industry legislation.

Smoke-free legislation is implemented to protect non-smokers from the harms of second-hand smoke. Smoke-free legislation can thus reduce tobacco related deaths. Smoke-free laws can possibly also stimulate smokers to quit smoking. Because this reduces the percentage of smokers, this also reduces the number of tobacco related deaths. But perhaps even more important is that a lower percentage of smokers means that there are more non-smokers in the population. This causes societal support for tobacco control policies to grow in the population. More support for tobacco control causes policy measures to be implemented, which eventually causes less and less people to smoke in the population. For that reason, I have focused on the impact of smoke-free legislation on smoking cessation in my PhD thesis.

When it became clear that second-hand smoke is dangerous for non-smokers, many countries implemented smoke-free legislation in public buildings and public transport. The next stage was in many countries that workplaces became smoke-free. Restaurants and bars are exempted in some countries at first, but become smoke-free later on. This is also what happened in the Netherlands. The Netherlands started in 1990 with smoke-free government buildings and public buildings. In 2004, smoke-free workplace legislation was implemented. Public transport also become smoke-free, but the hospitality industry was exempted. In 2008, smoke-free hospitality industry legislation was implemented.

I started my research by studying data from the Continuous Survey of Smoking Habits. This is a national population survey among large groups of respondents which are representative for the Dutch population. Based on this data, we found that the implementation of smoke-free workplace legislation in 2004 in the Netherlands reduced smoking prevalence and caused a temporary increase in quit attempts and quit success. The implementation of smoke-free hospitality industry legislation in 2008 did not have a significant impact on smoking prevalence and had a smaller impact on quit attempts and on quit success. It seems that the effect of smoke-free legislation is larger when it is implemented in all workplaces instead of only the hospitality industry.

The results of another study indicated that the effect of comprehensive smoke-free legislation is larger than the effect of partial smoke-free legislation.

The effect of tobacco control policy can also be examined with a simulation model in which all knowledge about the effect of tobacco control policies on smoking is combined. When I was halfway through my PhD project, I was involved in the Dutch SimSmoke simulation project. SimSmoke can model the effect of tobacco control policy measures on changes in smoking prevalence and tobacco related deaths. According to the calculations that we performed with the model, there will be more than a million tobacco related deaths in the Netherlands between 2011 and 2040 when no new policies are implemented. With a comprehensive package of tobacco control policy measures this number can be reduced to less than 900,000. These measures can thus ‘save’ almost 145,000 lives. By this is meant that this number of people will not die prematurely by tobacco related diseases. The most effective measures for the Netherlands are tax policies, cessation treatment policies, ánd extending the current smoke-free legislation to a comprehensive law for all workplaces and public places. However, as mentioned before I have not focused on all these measures in my PhD thesis, but only on the measures that were implemented in 2008. I have focused mostly on the implementation of smoke-free hospitality industry legislation.

I am trained as a Communications Scientist and, therefore, I thought it would be interesting to examine the media coverage about the smoke-free hospitality industry legislation in the Netherlands. I have analysed 1,041 newspaper articles about the smoke-free hospitality industry legislation from six Dutch newspapers, together with two collegues. As you can see in this graph, the newspaper coverage was mostly about the economic aspects of the smoke-free legislation. We found much less newspaper articles on health aspects of the legislation. Also, there was more and more coverage about the growing resistance against the legislation. Newspaper coverage was twice as often negative than positive about the smoke-free hospitality industry legislation. Reading these newspapers seemed to have a small negative effect on support for smoke-free hospitality industry legislation.

The implementation campaign for the smoke-free hospitality industry legislation was not about second-hand smoke in the Netherlands. It was about a man dressed as a cigarette who was literally thrown out of hospitality venues. This campaign had no impact on support for smoke-free hospitality industry legislation. These results and reading al those negative newspaper messages got me thinking. Could there have gone something wrong with the implementation of smoke-free legislation in the Netherlands?

How smoke-free legislation should be implemented, was already established by the World Health Organisation in 2007, based on experiences in other countries. Four points are important according to the World Health Organisation: They advice to implement a 100% comprehensive ban without smoking rooms or exceptions, to ensure strong enforcement and to run an educational campaign about the harm of second-hand smoke. In the Netherlands, none of the four recommendations were followed. Until then, it was not studied whether countries that did not follow the recommendations were also less successful with their smoke-free legislation. We did examine this.

We have performed a country comparison for which we had data from Ireland, France, Germany, and the Netherlands. These are the European countries from the International Tobacco Control Policy Evaluation Project or ITC project. ITC is an international survey in which smokers are followed through time and in which the Netherlands participates since 2008. ITC is specially designed to rigorously examine the effects of tobacco control policy measures on smokers, so other countries can learn from this.

Ireland followed all four recommendations from the World Health Organisation and France almost all. In France, smoking rooms are allowed, but the conditions for smoking rooms are so strict that almost no hospitality owner makes a smoking room. Germany and the Netherlands have not followed any of the four recommendations of the World Health Organisation.

As expected, Ireland and France were much more effective in reducing smoking in bars than the Netherlands and Germany. This indicates that countries that follow the four recommendations are much more successful than countries that don’t follow them. In addition to the country level, we have also examined on the individual level what determines whether someone smokes inside a bar after the implementation of smoke-free legislation. Smokers who were in favor of smoke-free legislation and who were more aware of the harm of second-hand smoke were less likely to smoke in bars after the implementation of smoke-free legislation.

In another study that specifically examined support for smoke-free legislation among smokers, we found that support for smoke-free bars increased after the implementation of comprehensive smoke-free legislation. It increased less after the implementation of partial smoke-free legislation. Again, there are indications that smoke-free legislation must be implemented comprehensively, without exceptions and without smoking rooms.

What we didn’t know was how an effect of smoke-free legislation on smoking cessation comes about, through which individual pathways of change. Insight into this question is very important because it can learn us how we can increase the impact of smoke-free legislation on smokers. We used the ITC Conceptual Model. According to the ITC Conceptual Model, tobacco control policy can have an impact on smoking cessation through certain individual pathways of change. First, the policy influences opinions and thoughts that are strongly related to the policy. These opinions and thoughts then influence more general psychological factors that are less related with the policy and more with smoking cessation. Finally, these psychosocial mediators can have an influence on actual smoking cessation.

With Structural Equation Modeling analyses we arrived at this model. The effect of individual exposure to smoke-free legislation on smoking cessation could be explained by an effect on support for smoke-free legislation, and an impact of this on attitudes about quitting and intention to quit smoking. As with the last study, we found again that support for smoke-free legislation among smokers is very important.

Of course, only few smokers quit smoking after the implementation of smoke-free legislation. Therefore, we have examined whether there would be unintended consequences for continuing smokers. Unfortunately, a common unintended consequence of tobacco control is an increase in socioeconomic differences in smoking. Our results show that the implementation of smoke-free hospitality industry legislation in the Netherlands did not increase socioeconomic differences in smoking, but smoke-free workplace legislation did. In a further study in which we used data from the Continuous Survey of Smoking Habits, we found that socioeconomic differences in smoking were widening in the Netherlands.

Another often mentioned unintended consequence of smoke-free legislation is that it would cause smokers to smoke more at home. We examined this in one of our last studies. The smoke-free hospitality industry legislation did not increase smoking in the own home. It even seems like smoke-free legislation caused a reduction in the number of cigarettes smoked per day. Smoke-free legislation also seemed to stimulate smokers to make their homes completely smoke-free. Support for smoke-free legislation was an important predictor of making the own home smoke-free.

In the very last study we examined possible unintended consequences on feelings of stigmatisation among smokers. In the Netherlands, the implementation of smoke-free hospitality industry legislation did not increase feelings of stigmatization.

Concluding, we can say that national smoke-free legislation can stimulate smoking cessation. In this process, support for smoke-free legislation among smokers is an important mechanism. Enough support for smoke-free legislation among smokers also ensures more compliance with the law and less smoking at home. Media attention about the harm of second-hand smoke for non-smokers can possibly increase support for smoke-free. Also, comprehensive smoke-free legislation has a more positive effect on support for smoke-free legislation among smokers than partial smoke-free legislation.

Priorities for the Netherlands are first to run an educational campaign in which it is explained that smoke-free hospitality industry legislation is needed to protect non-smokers from the harm of second-hand smoke. Second, Netherlands should implement a comprehensive smoke-free hospitality industry law, without exceptions and without smoking rooms.

It has been done elsewhere, it can be done everywhere.”

Gera Nagelhout defending her PhD thesis

Gera Nagelhout defending her PhD thesis

I mostly think that doing trend analyses is exciting and interesting. Especially when you have data from many years that no one has ever examined for trends before. However, trends can also be annoying and difficult, because sometimes you can interpret them in several ways. I encountered a trend of the latter category when I was examining data about the image of non-smoking youth from 2001 until 2011.

Let me quickly explain a bit about the data. We used data from surveys among youth from the Netherlands aged 10 to 19 years old. The survey was repeated every year among about 4,500 youngsters. In total, 50,146 youngsters were surveyed between 2001 and 2011. They were asked: “What do you think of young people who do not smoke?” On a scale from 1 to 7 they could indicate whether they thought young people who do not smoke are cool or uncool, kind or unkind, strong or weak, attractive or unattractive, etc. (9 items). These items were taken together in one ‘image of non-smoking scale’ ranging from 1 (negative) to 7 (positive).

The trend is shown in the figure below. In 2001, youth scored 5.13 on the ‘image of non-smoking scale’. In 2011, this was significantly higher with a score of 5.33. Trend analyses that controlled for demographic characteristics and smoking behaviour found a significant positive trend. Or more concrete: the percentage of youth who reported that non-smoking youth were cool increased from 49% in 2001 to 63% in 2011.

We concluded in our report (in Dutch): “Even though the image of non-smoking youth was already quite positive in 2001, it even got more positive afterwards”. In contrast, the media reports about our study wrote: “The image of non-smoking youth has deteriorated”. I’ll explain how this could have happened.

After writing the report, we decided to issue a press release. In the press release we wrote that the image of non-smoking youth had hardly improved since 2001. We did this because we believed that an improvement of 5.1 to 5.3 on a scale from 1 to 7 was only statistically significant (possibly due to our large sample size) but not really practically relevant. Later on in the press release we also wrote about our concerns about the significant decrease in the image of non-smoking youth between 2008 and 2011 (see figure), which could have been caused by the recent budget cuts on youth smoking prevention. This last point was picked up by the media: the image of non-smoking youth has deteriorated.

In short, our trend looked like an unambiguous positive trend at first. In the press release we decided to frame the trend as hardly any change. Finally, the media reported about the most recent deteriorations in the trend of the image of non-smoking youth. All three interpretations are correct and supported by the data, but altogether I can’t really say anymore whether the image of non-smoking youth has improved or not. It seems like you need just one extra datapoint to be sure, but this feeling comes back every year. As I was saying at the beginning: some trends can be annoying and difficult.

This blog post is about how to write papers with many co-authors. Although writing papers with many co-authors can be challenging, I think it can also be a great learning experience that can lead to better papers. Based on my personal experience, I have made a list with recommendations that may be helpful to read before starting a writing project with more than six other researchers.

1 – Start with a contributor statement

This may sound strange, but it can be helpful to draft a contributor statement BEFORE asking others to contribute to your paper. You may not want to circulate this draft contributor statement to your co-authors before they have contributed, but writing it can help you make explicit for yourself why you are involving all these people.

For example: Researcher A is involved to advise you on the study design and writing. researcher B provides statistical advise. Researchers C, D and E are involved to provide background information about country X, Y and Z. And researcher F is an expert on the topic that you write about.

Always add the contributor statement to your manuscript before submission. A contributor statement is not always required by the journal, but editors often ask for it anyway when your list of co-authors is long.

2 – Find main comments

Some co-authors provide very detailed comments whereas others only tell you their main concerns. It is up to you to find out what everyones main comment is. When you found them, you have two choices depending on whether you agree or disagree with the comment. The first is to listen to the co-author and do as they say. Alternatively, you can choose to not make the recommended change, but you should clearly explain why not. Never  ignore someones main comment! If appropriate, you can explain your choices in the manuscript, because it is not uncommon for reviewers to make the same comments as your co-authors.

3 – Find similar comments

After processing all main comments, you are left with a lot of smaller comments which you can feel free to accept or reject as you wish. However, some smaller comments may be mentioned by two or more of your co-authors. These similar comments need to be treated like main comments (see point 2 above).

4 – Keep track of time

Writing a paper with many co-authors does not necessarily have to be a lengthy process, but if you do not keep track of time it will be. Set deadlines for commenting on the draft paper and immediately send out reminders if someone has not commented within the deadline. When a potential co-author is not able to comment within the deadline, decide whether you are willing to extent the deadline to keep someone involved or whether you need to go on without that person as co-author.

5 – Check the journal policy

Some journals have a maximum number of co-authors. If you really want to submit to such a journals, explain in your cover letter why you needed to involve more co-authors. Comparing several countries is often seen as a valid reason.

6 – Look at the bright side

Do not wallow too long about the difficulties of writing with many co-authors. Look at the bright side! You can learn lots from all these people, which can lead to a better paper. Also, you are much better prepared for reviewer comments. When you write a paper with only one co-author you may be inclined to do everything the other says (especially when this person is your supervisor). When you have several co-authors, they will disagree about certain points and you are forced to think for yourself and make your own choices. This will make you a better researcher.

My experience from writing with many co-authors comes from my participation in the International Tobacco Control Policy Evaluation Project (or ITC Project) that is being conducted in 23 countries worldwide. As part of the SILNE Project, I am currently comparing data from the six European ITC Project countries to examine the impact of tobacco control policies on socioeconomic inequalities in smoking cessation. Most of the papers I have published have six or more co-authors and I’m currently finalising a paper with 11 co-authors.

Imagine you are a smoker who loves to socialise, drink and smoke inside a bar. Suddenly, a smoke-free law is introduced and you are ‘forced’ to smoke outside. How does this make you feel? According to the tobacco control literature, this situation may cause smokers to feel ashamed, an outcast or even like a leper. However, when we studied this phenomenon in the Netherlands, we did not find that feelings of stigma increased after implementation of the smoke-free law or when smokers are smoking outside.

About one and a half years ago I started to work on the question whether the smoke-free law in the Netherlands increased feelings of stigmatization together with a Master’s student. We used data from the International Tobacco Control Policy Evaluation Project, which is a quantitative longitudinal study among a representative sample of smokers. We were aware of only one previous study that examined the same question with quantitative data. This study found no association between smoke-free laws and stigma among smokers in New York City. Our findings were similar. Overal feelings of stigma did not change after the implementation of the smoke-free law in the Netherlands. Increased feelings of stigma were found only among smokers who felt negatively judged by passers-by when smoking outside bars. However, most smokers in the Netherlands did not feel negatively judged when smoking outside.

A few months later I was involved in another study with a similar research question but different methods. Qualitative interviews were conducted among lower educated smokers to examine their psychological responses to the smoke-free law. The smokers were interviewed once, which was two years after the implementation of the smoke-free law. Some smokers reported increased feelings of social exclusion. However, it did not became clear that this changed after the implementation of the smoke-free law. In fact, some smokers explicitly talked about a process that had been going on for a longer time period.

Although we did not find that smokers’ stigma increased after the smoke-free law in the Netherlands, I’m not convinced that it may not happen elsewhere. In the Netherlands, smoke-free legislation is not comprehensive (smoking rooms are allowed) and there are high levels of non-compliance among bars. In a country with more comprehensive smoke-free legislation or where smoking is more denormalised, there may be more unintended consequences for continuing smokers. However, the most important question is not whether a smoke-free law increases stigma but whether that’s a problem.

If you look at the bigger picture, increased smokers’ stigma due to the implementation of a smoke-free law is not a real issue. At least, the advantages of smoke-free laws for non-smokers by far outweigh the possible unintended consequences for continuing smokers. The implementation of smoke-free laws should therefore continue. But if you focus on the individual smoker who starts to feel like an outcast, it becomes clear that there is a problem that should be taken seriously. Policy makers have the moral responsibility to support these individuals, for example by providing free cessation counseling and medication for those who want to quit but cannot do it by themselves. This policy is important because it implicitly communicates that smokers are not outcasts or lepers, but are worth helping. I definitely think that it can help to implement this kind of support alongside smoke-free legislation.

Meeroken vergroot de kans op longkanker, hartaandoeningen en luchtwegaandoeningen. In Ierland is daarom al in 2004 besloten om alle werknemers te beschermen tegen het inademen van tabaksrook. In Nederland staat echter nog steeds de helft van de horecamedewerkers (en de bezoekers) in de rook. Toch is een écht rookvrije horeca ook mogelijk in Nederland.

Wereldgezondheidsorganisatie

De Wereldgezondheidsorganisatie heeft in 2003 de Framework Convention on Tobacco Control (FCTC) geïnitieerd.[1] Dit verdrag is inmiddels door meer dan 170 landen, waaronder Nederland, geratificeerd. Het ratificeren betekent dat landen verplicht zijn om de maatregelen te nemen die in de FCTC staan beschreven.

In artikel 8 van de FCTC staat dat landen niet-rokers volledig moeten beschermen tegen het inademen van tabaksrook. Dit houdt in dat er geen uitzonderingen zijn, dat het niet is toegestaan om rookruimtes in te richten en dat de handhaving optimaal is.[2] Aan deze voorwaarden wordt in Nederland niet voldaan.[3] In Nederland zijn kleine cafés zonder personeel uitgezonderd, is het toegestaan om rookruimtes in te richten, en houden veel grotere cafés zich niet aan het rookverbod omdat de pakkans klein is. Uit de meest recente cijfers van de Nederlandse Voedsel- en Warenautoriteit blijkt dat de helft van de cafés die onder het rookverbod vallen zich hier niet aan houdt.[4]

Rookvrije horeca 2004 – 2012

Al jaren wordt in Nederland geprobeerd de horeca rookvrij te maken. Het begon in 2004 toen in Nederland de rookvrije werkplek werd ingevoerd. Omdat er te weinig (politiek) draagvlak was voor een rookvrije horeca, werd de horeca tijdelijk vrijgesteld van het invoeren van een rookvrije werkplek. Er werd een stappenplan gemaakt dat moest zorgen dat ook de horeca op termijn rookvrij zou worden. In 2006 concludeerde de Nederlandse regering echter dat het stappenplan niet voldoende werkte. In 2007 werd daarom besloten om de uitzondering voor de horeca op te heffen. Per 1 juli 2008 werd in Nederland de horeca rookvrij.

De invoering van de rookvrije horeca stuitte in Nederland op verzet van kleine caféhouders. Rechtszaken zorgden voor een tijdelijke opschorting van de handhaving van het rookverbod voor eenmanszaken vanaf juli 2009. In februari 2010 kwam er duidelijkheid, toen de Hoge Raad besloot dat het rookverbod rechtsgeldig was voor alle horecagelegenheden. Hoewel het draagvlak voor de rookvrije horeca onder de bevolking steeds verder steeg[5], kondigde minister Schippers eind 2010 aan dat ze het rookverbod voor eenmanszaken terug ging draaien. Vanaf juli 2011 werd de opschorting van de rookvrije horeca voor kleine cafés zonder personeel definitief door een wetswijziging. Clean Air Nederland spande in 2012 een rechtszaak aan tegen de Staat om dit besluit terug te draaien, maar de Staat won. Het percentage cafés en discotheken die het rookverbod overtreden, was inmiddels meer dan verdubbeld van 17% in 2009 naar 44% in 2012.[4]

Gedeeltelijk versus volledig rookvrij

In Nederland is de horeca dus (nog) niet écht rookvrij, maar slechts gedeeltelijk. Landen als Engeland en Ierland hebben wel een volledig rookverbod ingevoerd. Het invoeren van deze rookverboden verliep vrijwel probleemloos. Bijna iedereen houdt zich er netjes aan en er is veel draagvlak onder de bevolking. Uit onderzoek blijkt dan ook dat juist volledige rookverboden op veel draagvlak onder rokers kunnen rekenen[6] en dat draagvlak onder rokers een belangrijke voorwaarde is voor een goede naleving[7].

Alleen een volledig rookverbod voor alle werkplekken zonder uitzonderingen en zonder rookruimtes kan niet-rokers voldoende beschermen tegen de schade van meeroken.[8] Een volledig rookverbod heeft grotere effecten op het verbeteren van de luchtkwaliteit[8, 9], op het verminderen van blootstelling aan tabaksrook[10, 11] en op het verminderen van hartinfarcten[12] dan gedeeltelijke rookverboden. Recent onderzoek liet dan ook zien dat de gedeeltelijk rookvrije horeca in Nederland niet heeft geleid tot minder hartstilstanden.[13]

Ten slotte suggereert recent onderzoek dat volledige rookverboden rokers kunnen stimuleren om te stoppen met roken, terwijl dit minder het geval is bij gedeeltelijke rookverboden.[14] Berekend is dat door het uitbreiden van het gedeeltelijke rookverbod in Nederland naar een volledig rookverbod het percentage rokers in 2040 gedaald kan zijn naar 21% en dat door deze daling ruim 27.000 levens gered worden.[15]

Kortom, een volledig rookverbod is essentieel om mensen te beschermen tegen de schade van meeroken en kan rokers stimuleren om te stoppen met roken.

Hoe komt het?

De Wereldgezondheidsorganisatie beveelt aan om alle werkplekken volledig rookvrij te maken zonder rookruimtes en uitzonderingen, een goede handhaving te organiseren en een goede voorlichtingscampagne over de schade van meeroken te voeren.[2] De Nederlandse regering heeft ervoor gekozen om zich niet aan deze aanbevelingen te houden.

Volgens officiële bronnen is de keuze voor een gedeeltelijk in plaats van een volledig rookvrije horeca in Nederland ingegeven door de wensen en behoeften van horecaondernemers.[16, 17] Het is echter bekend dat de tabaksindustrie in veel landen heeft geprobeerd om volledige rookverboden tegen te houden.[18] De strategie die ze daarbij gebruiken, is het financieren of juridisch ondersteunen van horecaorganisaties om zich tegen een volledig rookverbod te verzetten. De Nederlandse stichting Red de Kleine Horeca Ondernemer die voor een uitzondering voor kleine cafés heeft gestreden, bleek banden te hebben met de tabaksindustrie.[19]

De invloed van horecaondernemers en mogelijk ook de tabaksindustrie op de Nederlandse regering kan verklaren waarom in Nederland gekozen is voor het toestaan van rookruimtes en het terugdraaien van het rookverbod voor kleine cafés zonder personeel.

Wat nu?

Het creëren van voldoende draagvlak voor een volledig rookvrije horeca is van groot belang. Met een goede voorbereiding en communicatie over de schade van meeroken zou het mogelijk moeten zijn om het draagvlak voor een volledig rookvrije horeca te vergroten. Het is niet aannemelijk dat Nederland hierin verschilt van andere landen. De Nederlandse tolerante poldercultuur heeft het de tabaksindustrie waarschijnlijk wel makkelijker gemaakt om invloed uit te oefenen op het ontwerpen en gedeeltelijk terugdraaien van het rookverbod. Echter, als rokers duidelijk wordt gemaakt dat meeroken zo schadelijk is dat je dat anderen niet aan kan doen, zullen ze de invoering van een volledig rookverbod steunen. En als de Nederlandse regering vervolgens een volledig rookverbod invoert waarbij wordt voldaan aan de aanbevelingen van de Wereldgezondheidsorganisatie, zou een succesvolle implementatie van een écht rookvrije horeca ook mogelijk moeten zijn in Nederland. Zoals het Smoke Free Partnership, een Europese organisatie die strijdt voor een rookvrij Europa, het formuleerde: “It has been done elsewhere, it can be done everywhere”.[20]

Vanuit internationaal vergelijkend onderzoek weten we steeds meer over het invoeren van succesvolle rookverboden. Wat deze internationale ervaringen nu concreet betekenen voor Nederland is nog de vraag. Vindt u het interessant om hier meer over te weten of debatteert u graag mee? Op 10 oktober organiseren wij een internationaal symposium over rookverboden en verdedigt Gera Nagelhout haar proefschrift over het effect van rookverboden op rokers. Meer informatie en registratie: bit.ly/10Oct12info

Gepubliceerd als

Nagelhout, G. E., Willemsen, M. C., & De Vries, H. (2012). Een écht rookvrije horeca is ook mogelijk in Nederland. Tijdschrift voor Gezondheidswetenschappen, 90, 344-346.

English abstract

Second-hand smoking increases the risk of lung cancer, heart diseases, and respiratory diseases. The Irish government already decided to protect all employees against exposure to second-hand smoke in 2004. In the Netherlands, half of hospitality industry employees (and visitors) remain exposed to tobacco smoke. Nonetheless, a truly smoke-free hospitality industry is also possible in the Netherlands provided that the recommendations from the World Health Organization (100% smokefree legislation without smoking rooms, without exceptions, with adequate enforcement, and with an educational campaign about the harms of second-hand smoke) are followed through. It has been done elsewhere, it can be done everywhere.

International symposium

We are organizing an international symposium on smoke-free legislation on October 10, 2012 in Maastricht. Three international experts will speak at this symposium: Dr. Esteve Fernández (Spain), Ute Mons (Germany), and Professor Geoffrey Fong (Canada). A panel discussion will be organized where the international experts and important national stakeholders discuss the current situation in the Netherlands with respect to smoke-free legislation. More information at bit.ly/10Oct12info

Referenties

1.         World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization, 2003.

2.         World Health Organization. Protection from exposure to second-hand tobacco smoke. Policy recommendations. Geneva: World Health Organization, 2007.

3.         Rennen E, Willemsen MC. Dutch tobacco control: Out of control? Amsterdam: KWF Kankerbestrijding, 2012.

4.         Voedsel en Waren Autoriteit, Intraval. Inventarisatie naleefniveau rookvrije horeca voorjaar 2012. Voedsel en Waren Autoriteit & Intraval, 2012.

5.         Nagelhout GE, Zeegers TMC, Meer RM van der, Segaar D, Willemsen MC. Themapublicatie: Voorstanders van rookvrije horeca in Nederland 2003-2012. Den Haag: STIVORO, 2012.

6.         Mons U, Nagelhout GE, Guignard R, McNeill A, Putte B van den, Willemsen MC, Brenner H, Pötschke-Langer M, Breitling LP. Comprehensive smoke-free policies attract more support from smokers in Europe than partial policies. Eur J Public Health 2012;22(Suppl 1):10-16.

7.         Nagelhout GE, Mons U, Allwright S, Guignard R, Beck F, Fong GT, Vries H de, Willemsen MC. Prevalence and predictors of smoking in “smoke-free” bars. Findings from the International Tobacco Control (ITC) Europe Surveys. Soc Sci Med 2011;72:1643-1651.

8.         Hahn EJ. Smokefree legislation: A review of health and economic outcomes research. Am J Prev Med 2010;39(Suppl 1):66-76.

9.         Gleich F, Mons U, Pötschke-Langer M. Air contamination due to smoking in German restaurants, bars, and other venues – Before and after the implementation of a partial smoking ban. Nic Tob Res 2011;13:1155-1160.

10.       López MJ, Nebot M, Schiaffino A, Pérez-Ríos M, Fu M, Ariza C, Muñoz G, Fernández E, on behalf of the Spanish Smoking Law Evaluation Group. Two-year impact of the Spanish smoking law on exposure to secondhand smoke: Evidence of the failure of the ‘Spanish model’. Tob Control. Published Online First: June 9 2011.

11.       Naiman A, Glazier R, Moineddin R. Is there an impact of public smoking bans on self-reported smoking status and exposure to secondhand smoke? BMC Public Health 2011;11:146.

12.       Ferrante D, Linetzky B, Virgolini M, Schoj V, Apelberg B. Reduction in hospital admissions for acute coronary syndrome after the successful implementation of 100% smoke-free legislation in Argentina: A comparison with partial smoking restrictions. Tob Control. Published Online First: 20 May 2011.

13.       Korte-de Boer D de, Kotz D, Viechtbauer W, Haren E van, Grommen D, Munter M de, Coenen H, Gorgels APM, Schayck OCP van. Effect of smoke-free legislation on the incidence of sudden circulatory arrest in the Netherlands. Heart 2012;98:995-999.

14.       Nagelhout GE, Vries H de, Allwright S, McNeill A, Putte B van den, Boudreau C, Fong GT, Willemsen MC. Comparative impact of smoke-free legislation on smoking cessation in three European countries. Eur J Public Health 2012;22(Suppl 1):4-9.

15.       Nagelhout GE, Levy DT, Blackman K, Currie L, Clancy L, Willemsen MC. The effect of tobacco control policies on smoking prevalence and smoking-attributable deaths. Findings from the Netherlands SimSmoke Tobacco Control Policy Simulation Model. Addiction 2012;107:407-416.

16.       Klink A. Kamerbrief rookvrije horeca. Den Haag: Ministerie van Volksgezondheid, Welzijn en Sport, 2007.

17.       Schippers EI. Kamerbrief uitvoering uitzondering rookvrije horeca. Den Haag: Ministerie van Volksgezondheid, Welzijn en Sport, 2010.

18.       Gonzalez M, Glantz SA. Failure of policy regarding smokefree bars in the Netherlands. Eur J Public Health, Published Online First: 5 December 2011.

19.       Baltesen F, Rosenberg E. Tabakssector betaalt verzet rookverbod. NRC Handelsblad, p. 1, 2009.

20.       Smoke Free Partnership. Lifting the smokescreen. 10 reasons for a smoke free Europe. Brussels: European Respiratory Society Brussels Office, 2006.

When I was in college, I was very annoyed when I had to read English language papers that were written by my Dutch professors. Couldn’t they just have written it in their mother tongue? I did not understand back then why they would publish in English. Nowadays, I am a researcher myself and I mostly write, blog, tweet and publish in English. After all, why would I write in a language that 99% of the world cannot understand?

Groundbreaking research findings with universal implications should no doubt be published in English. It would be a loss for the rest of the world when these findings are ‘hidden’ in another language. Already it is very common to publish almost every research study in English, but this is mostly the result of publishing requirements from universities. There are of course situations when you should publish in your native language. When your target group is a national (medical) profession you cannot assume that they read international journals. Publishing in English would then limit the practical implemention of your research findings. Also, research that is of local importance should probably be published in the local language.

Research findings that are both important for the international community and for your own country can benefit from a combination approach. You could take the trouble to publish your research in two languages, but there is a less time-consuming option. A native language press release about your English language paper can generate at least as much attention as a native language paper. One of my papers that was published in Social Science & Medicine and was accompanied by a Dutch press release generated quite some media attention and even resulted in parliamentary questions. We wanted to use the same approach with a paper published in Tobacco Control. However, the English language press release from the journal generated so much media attention that it was already in the Dutch media before we could issue the Dutch press release.

When researchers blog or tweet they can choose their language based on their own preference or their target audience. When I started using Twitter, I noticed that almost all my Dutch collegues tweet in Dutch. Convinced that I found an interesting ‘niche’ I started tweeting in English. I also started a Dutch tobacco control weekly newsletter in which I translate tweets about Dutch tobacco control to English. Currently, almost half of my followers are not from the Netherlands, so I guess that my English language mistakes and my occasional Dutch (re)tweet doesn’t bother them too much.

A lot of discussion is going on about whether research studies should be ‘locked’ behind publishers’ paywalls. Open access publishing is a great way to make your research accessible. Research that is locked behind a language barrier is also inaccessible.