The influence of school smoking policy and school prevention programs on the smoking behaviour of high school students in Prince Edward Island, Canada

The aim of the study was to examine the influence of school smoking policy and school smoking prevention programs on the smoking behaviour of students in high schools in Prince Edward Island using the School Health Action Planning Evaluation System (SHAPES). A total sample included 13,131 observations of students in grades 10-12 in ten high schools in Prince Edward Island over three waves of data collection (1999, 2000, and 2001). Changes in prevalence of smoking and factors influencing smoking behaviour were analyzed using descriptive statistics and Chi-Square tests. Multi-level logistic regression analyses were used to examine how both school and student characteristics were associated with smoking behaviour (I, II, III, IV). Since students were located within schools, a basic 2-level nested structure was used in which individual students (level 1) were nested within schools (level 2). For grade 12 students, the combination of both school policies and programs was not associated with the risk of smoking and the presence of the new policy was not associated with decreased risk of smoking, unless there were clear rules in place (I). For the grade 10 study, (II) schools with both policies and programs were not associated with decreased risk of smoking. However, the smoking behaviour of older students (grade 12) at a school was associated with younger students’ (grade 10) smoking behaviour. Students first enrolled in a high school in grade 9, rather than grade 10, were at increased risk of occasional smoking. For students who transitioned from grade 10 to 12 (III), close friends smoking had a substantial influence on smoking behaviour for both males and females (III). Having one or more close friends who smoke (Odds Ratio (OR) = 37.46; 95% CI = 19.39 to 72.36), one or more smokers in the home (OR = 2.35; 95% CI = 1.67 to 3.30) and seeing teachers and staff smoking on or near school property (OR=1.78; 95% CI = 1.13 to 2.80), were strongly associated with increased risk of smoking for grade 12 students. Smoking behaviour increased for both junior (Group 1) and senior (Group 2) students (IV). Group 1 students indicated a greater decrease in smoking behaviour and factors influencing smoking behaviour compared to those of Group 2. Students overestimating the percentage of youth their age who smoke was strongly associated with increased likelihood of smoking. Smoking rates showed a decreasing trend (1999, 2000, and 2001). However, policies and programs alone were not successful in influencing smoking behaviour of youth. Rather, factors within the students and schools contextual environment influenced smoking behaviour. Comprehensive approaches are required for school-based tobacco prevention interventions. Keywords: schools, policy, programs, smoking prevention, adolescents Subject Terms: school-based programming, public health, health promotion

Impact of Tobacco Control Policy on Smoking and Exposure to Environmental Tobacco Smoke

The aim of the study was to evaluate the impact of the Finnish tobacco control measures for reduction of smoking. First, the trends and patterns in ever smoking among adult Finns in 1978 2001 as well as the associations of trends with the Tobacco Control Act in 1976 were examined. Secondly, the impact of the 1976 TCA on the proportion of ever daily smokers in different socioeconomic groups was studied. Thirdly, the impact of the 1995 TCAA on recent trends in the prevalence of daily smoking was evaluated by gender and employment status. Fourthly, the trends of exposure to environmental tobacco smoke (ETS) at workplaces and homes were investigated. The study is based on data of the Health Behaviour among the Finnish Adult Population surveys. Among Finnish men smoking initiation declined from earlier to later cohorts, whereas among women it increased in successive birth cohorts born before 1956. The lasting differences between birth cohorts as regards ever daily smoking reflected well the impact of measures to reduce smoking in Finland in 1976. Smoking initiation in the birth cohorts (born in 1961 or later) which were in critical age as regards the risk of smoking initiation when the TCA came into force was less common than could be expected according to the trends seen in the earlier birth cohorts. Marked socioeconomic differences were found in smoking in the different birth cohorts. Smoking was more prevalent in the lower socioeconomic groups than in the higher ones, and the differences were larger in the later birth cohorts compared to the earlier ones. The differences between the birth cohorts in ever daily smoking were compatible with the hypothetical impact of the TCA in almost all socioeconomic groups, except farmers. Among men the 1976 TCA appears to have had the greatest impact on white-collar employees. Among women the effect of the act was highly significant in all socioeconomic groups. However, female smoking prevalence continues to show wide socioeconomic disparities. Daily smoking decreased among employees after the 1995 TCAA, supporting the hypothesis of the lowering impact of the amendment on daily smoking due to increased smoking cessation. No parallel change in daily smoking was found in the population without direct expose to ETS legislation (farmers, students, housewives, pensioners or unemployed). Exposure to ETS decreased markedly among non-smokers at work after the 1995 TCAA. The 1976 TCA and the 1995 TCAA were useful in controlling smoking initiation and cessation, but their impact was not equal across the population groups. The results of this study strongly suggested that tobacco control policies markedly contribute to the decrease in smoking and in exposure to environmental tobacco smoke.

Stalking and violence victimization among Finnish university students

This study examined the nature and lifetime prevalence of two types of victimization among Finnish university students: stalking and violence victimization (i.e. general violence). This study was a cross-sectional study using two different datasets of Finnish university students. The stalking data was collected via an electronic questionnaire and the violence victimization data was collected via a postal questionnaire. There were 615 participants in the stalking study (I-III) and 905 participants in the violence victimization study. The thesis consists of four studies. The aims regarding the stalking substudies (Studies I-III) were to examine the lifetime prevalence of stalking among university students and to analyze how stalking is related to victim and stalker characteristics and certain central variables of stalking (victim-stalker relationship, stalking episodes, stalking duration). Specifically, the aim was to identify factors that are associated with stalking violence and to factors contributing to the stalking duration. Furthermore, the aim was also to investigate how university students cope with stalking and whether coping is related to victim and stalker background characteristics and to certain other core variables (victim-stalker relationship, stalking episodes, stalking duration, prior victimization, and stalking violence). The aims for the violence victimization substudy (Study IV) were to examine the prevalence of violence victimization, i.e. general violence (minor and serious physical violence and threats) and how violence victimization is associated with victim/abuser characteristics, symptomology, and the use of student health care services. The present study shows that both stalking and violence victimization (i.e. general violence) are markedly prevalent among Finnish university students. The lifetime prevalence rate for stalking was 48.5% and 46.5% for violence victimization. When the lifetime prevalence rate was restricted to violent stalking and physical violence only, the prevalence decreased to 22% and 42% respectively. The students reported exposure to multiple forms of stalking and violence victimization, demonstrating the diversity of victimization among university students. Stalking victimization was found to be more prevalent among female students, while violence victimization was found to be more prevalent among male students. Most of the victims of stalking knew their stalkers, while the offender in general violence was typically a stranger. Stalking victimization often included violence and continued for a lengthy period. The victim-stalking relationship and stalking behaviors were found to be associated with stalking violence and stalking duration. Based on three identified stalking dimensions (violence, surveillance, contact seeking), the present study found five distinct victim subgroups (classes). Along with the victim-stalker relationship, the victim subgroups emerged as important factors contributing to the stalking duration. Victims of violent stalking did not differ greatly from victims of non-violent stalking in their use of behavioral coping tactics, while exposure to violent stalking had an effect on the use of coping strategies. The victim-offender relationship was also associated to a set of symptoms regarding violence victimization. Furthermore, violence victimization had a significant main effect on specific symptoms (mental health symptoms, alcohol consumption, symptom index), while gender had a significant main effect on most symptoms, yet no interaction effect was found. The present results also show that victims of violence are overrepresented among frequent health care users. The present findings add to the literature on the prevalence and nature of stalking and violence victimization among Finnish university students. Moreover, the present findings stress the importance of violence prevention and intervention in student health care, and may be used as a guideline for policy makers, as well as health care and law enforcement professionals dealing with youth violence prevention.

Early Childhood Caries and a Community Trial of its Prevention in Tehran, Iran

Varhaislapsuuden karies ja sen ehkäisy kehittyvän terveydenhuollon maassa Varhaislapsuuden karies on merkittävä kansanterveysongelma varsinkin lapsirikkaissa maissa ja väestöissä. Karieksen hoitaminen vie paljon voimavaroja ja aiheuttaa mittavia taloudellisia seuraamuksia. Karies voi ilmaantua lapselle jo vauvaikäisenä, pian ensimmäisten maitohampaiden puhjettua suuhun. Alle 3-vuotiaiden karieksesta on kuitenkin niukasti tilastotietoja. Maailman terveysjärjestökin suosittaa tietojen keräämistä vasta 3-vuotiaiden ikäryhmästä. Heistä kariesta sairastaa Suomessa 16 %, Yhdysvalloissa 25 %, Englannissa 30 %, Iranissa 46 % ja Saudi-Arabiassa 61 %. Tämä väitöstutkimus selvitti karieksen esiintymistä ja sen vaaratekijöitä 1─3-vuotiailla Teheranissa. Lisäksi tutkimus arvioi perusterveydenhuoltoon sisällytetyn karieksen ehkäisyn tuloksellisuutta. Tutkimuskohteiksi arvottiin Teheranista 18 neuvolaa. Jokaisessa oltiin 4 päivää, jolloin kaikkia rokotuksiin tulleita 1─3-vuotiaita äiteineen pyydettiin osallistumaan tutkimukseen. Kahta lukuun ottamatta kaikki äidit suostuivat, ja aineistoon tuli kaikkiaan 504 lasta äiteineen. Kaikki 1-vuotiaat, 242 lasta äiteineen, valittiin karieksen ehkäisykokeiluun. Sitä varten neuvolat jaettiin kolmeen ryhmään, joista kaksi (A ja B) oli koeryhmiä ja yksi (C) oli vertailuryhmä. Tutkimus alkoi äidin haastattelulla. Siinä selvitettiin perheen koulutus- ja tulotaso sekä lapsen ruokinnasta imetyksen kesto, yösyötöt ja päiväaikaan nautitut makeat. Vielä kysyttiin lapsen ja äidin suuhygieniatavoista ja äidin kokemuksista lapsen suun puhdistamisessa. Sitten hammaslääkäri tutki lapsen suun ja kirjasi karieksen ja hammasplakin esiintymät. Suun tutkimuksen jälkeen äiti ja lapsi siirtyivät rokotushuoneeseen. Koeryhmissä (A ja B) äidit saivat terveydenhoitajalta suunterveyttä koskevan esitteen ja kehotuksen lukea se huolellisesti. Lisäksi ryhmässä A terveydenhoitaja kertoi suun ja hampaiden terveydenhoidosta saman esitteen avulla, ja neuvolan henkilökunta muistutti suunhoidon tärkeydestä puhelimitse kahdesti seuraavan puolen vuoden kuluessa. Vertailuryhmässä äideille ei annettu suunhoidon ohjeita. Kaikissa ryhmissä äitejä muistutettiin seuraavan rokotuskerran ajankohdasta, muttei mainittu tulevaa toista hammastarkastusta. Varhaislapsuuden kariesta sairasti ikäryhmästä riippuen 3─26 % tutkituista 1─3-vuotiaista, ja 65─76 %:lla oli hammasplakkia. Äideistä 68 % harjasi hampaansa päivittäin ja 39 % puhdisti lapsensa suun päivittäin. Mitä useammin äiti harjasi omat hampaansa, sitä paremmin hän huolehti lapsen suun puhtaudesta. Rintaruokinta oli yleistä eikä lisännyt kariesvaaraa. Yöllä pullomaitoa saavilla karies oli 5 kertaa yleisempää kuin muilla. Neuvolassa saatu ohjeistus ehkäisi selvästi karieksen syntyä puolen vuoden kokeessa.

Young Men s Sexual Behaviour in Finland and Estonia : Opportunities for prevention of sexually transmitted infections

Background: The incidence of sexually transmitted infections (STIs) in most EU states has gradually increased and the rate of newly diagnosed HIV cases has doubled since 1999. STIs differ in their clinical features, prognosis and transmission dynamics, though they do share a common factor in their mode of transmission −that is, human behaviour. The evolvement of STI epidemiology involves a joint action of biological, epidemiological and societal factors. Of the more immediate factors, besides timely diagnosis and appropriate treatment, STI incidence is influenced by population patterns of sexual risk behaviour, particularly the number of sexual partners and the frequency of unprotected intercourse. Assessment of sexual behaviour, its sociodemographic determinants and time-trends are important in understanding the distribution and dynamic of STI epidemiology. Additionally, in the light of the basic structural determinants, such as increased level of migration, changes in gender dynamics and impacts from globalization, with its increasing alignment of values and beliefs, can reveal future challenges related to STI epidemiology. STI case surveillance together with surveillance on sexual behaviour can guide the identification of preventive strategies, assess their effectiveness and predict emerging trends. The objective of this study was to provide base line data on sexual risk behaviour, self-reported STIs and their patterns by sociodemographic factors as well as associations of sexual risk behaviour with substance use among young men in Finland and Estonia. In Finland national population based data on adult men s sexual behaviour is limited. The findings are discussed in the context of STI epidemiology as well as their possible implications for public health policies and prevention strategies. Materials and Methods: Data from three different cross-sectional population-based surveys conducted in Finland and Estonia, during 1998 2005, were used. Sexual behaviour- and health-related questions were incorporated in two surveys in Finland; the Health 2000, a large scale general health survey, focussed on young adults, and the Military health behavioural survey on military conscripts participating in the mandatory military training. Through research collaboration with Estonia, similar questions to the Finnish surveys were introduced to the second Estonian HIV/AIDS survey, which was targeted at young adults. All surveys applied mail-returned, anonymous, self-administered questionnaires with multiple choice formatted answers. Results: In Finland, differences in sexual behaviour between young men and women were minor. An age-stratified analysis revealed that the sex-related difference observed in the youngest age group (18 19 years) levelled off in the age group 20 24 and almost disappeared among those aged 25 29. Marital status was the most important sociodemographic correlate for sexual behaviour for both sexes, singles reporting higher numbers of lifetime-partners and condom use. This effect was stronger for women than for men. However, of those who had sex with casual partners, 15% were married or co-habiting, with no difference between male and female respondents. According to the Military health behavioural survey, young men s sexual risk behaviour in Finland did not markedly change over a period of time between 1998 and 2005. Approximately 30−40% of young men had had multiple sex partners (more than five) in their lifetime, over 20% reported having had multiple sex partners (at least three) over the past year and 50% did not use a condom in their last sexual intercourse. Some 10% of men reported accumulation of risk factors, i.e. having had both, multiple sex partners and not used a condom in their last intercourse, over the past year of the survey. When differences and similarities were viewed within Finland and Estonia, a clear sociodemographic patterning of sexual risk behaviour and self-reported STIs was found in Finland, but a somewhat less consistent trend in Estonia. Generally, both, alcohol and drug use were strong correlates for sexual risk behaviour and self-reported STIs in Finland and Estonia, having a greater effect on engagement with multiple sex partners rather than unprotected intercourse or self-reported STIs. In Finland alcohol use, relative to drug use, was a stronger predictor of sexual risk behaviour and self-reported STIs, while in Estonia drug use predicted sexual risk behaviour and self-reported STIs stronger than alcohol use. Conclusions: The study results point to the importance for prevention of sexual risk behaviour, particularly strategies that integrate sexual risk with alcohol and drug use risks. The results point to the need to focus further research on sexual behaviour and STIs among young people; on tracking trends among general population as well as applying in-depth research to identify and learn from vulnerable and high-risk population groups for STIs who are exposed to a combination of risk factors.

Prevention of type 2 diabetes with lifestyle intervention - emphasis on dietary composition and identification of high-risk individuals

Type 2 diabetes is an increasing, serious, and costly public health problem. The increase in the prevalence of the disease can mainly be attributed to changing lifestyles leading to physical inactivity, overweight, and obesity. These lifestyle-related risk factors offer also a possibility for preventive interventions. Until recently, proper evidence regarding the prevention of type 2 diabetes has been virtually missing. To be cost-effective, intensive interventions to prevent type 2 diabetes should be directed to people at an increased risk of the disease. The aim of this series of studies was to investigate whether type 2 diabetes can be prevented by lifestyle intervention in high-risk individuals, and to develop a practical method to identify individuals who are at high risk of type 2 diabetes and would benefit from such an intervention. To study the effect of lifestyle intervention on diabetes risk, we recruited 522 volunteer, middle-aged (aged 40 - 64 at baseline), overweight (body mass index > 25 kg/m2) men (n = 172) and women (n = 350) with impaired glucose tolerance to the Diabetes Prevention Study (DPS). The participants were randomly allocated either to the intensive lifestyle intervention group or the control group. The control group received general dietary and exercise advice at baseline, and had annual physician's examination. The participants in the intervention group received, in addition, individualised dietary counselling by a nutritionist. They were also offered circuit-type resistance training sessions and were advised to increase overall physical activity. The intervention goals were to reduce body weight (5% or more reduction from baseline weight), limit dietary fat (< 30% of total energy consumed) and saturated fat (< 10% of total energy consumed), and to increase dietary fibre intake (15 g / 1000 kcal or more) and physical activity (≥ 30 minutes/day). Diabetes status was assessed annually by a repeated 75 g oral glucose tolerance testing. First analysis on end-points was completed after a mean follow-up of 3.2 years, and the intervention phase was terminated after a mean duration of 3.9 years. After that, the study participants continued to visit the study clinics for the annual examinations, for a mean of 3 years. The intervention group showed significantly greater improvement in each intervention goal. After 1 and 3 years, mean weight reductions were 4.5 and 3.5 kg in the intervention group and 1.0 kg and 0.9 kg in the control group. Cardiovascular risk factors improved more in the intervention group. After a mean follow-up of 3.2 years, the risk of diabetes was reduced by 58% in the intervention group compared with the control group. The reduction in the incidence of diabetes was directly associated with achieved lifestyle goals. Furthermore, those who consumed moderate-fat, high-fibre diet achieved the largest weight reduction and, even after adjustment for weight reduction, the lowest diabetes risk during the intervention period. After discontinuation of the counselling, the differences in lifestyle variables between the groups still remained favourable for the intervention group. During the post-intervention follow-up period of 3 years, the risk of diabetes was still 36% lower among the former intervention group participants, compared with the former control group participants. To develop a simple screening tool to identify individuals who are at high risk of type 2 diabetes, follow-up data of two population-based cohorts of 35-64 year old men and women was used. The National FINRISK Study 1987 cohort (model development data) included 4435 subjects, with 182 new drug-treated cases of diabetes identified during ten years, and the FINRISK Study 1992 cohort (model validation data) included 4615 subjects, with 67 new cases of drug-treated diabetes during five years, ascertained using the Social Insurance Institution's Drug register. Baseline age, body mass index, waist circumference, history of antihypertensive drug treatment and high blood glucose, physical activity and daily consumption of fruits, berries or vegetables were selected into the risk score as categorical variables. In the 1987 cohort the optimal cut-off point of the risk score identified 78% of those who got diabetes during the follow-up (= sensitivity of the test) and 77% of those who remained free of diabetes (= specificity of the test). In the 1992 cohort the risk score performed equally well. The final Finnish Diabetes Risk Score (FINDRISC) form includes, in addition to the predictors of the model, a question about family history of diabetes and the age category of over 64 years. When applied to the DPS population, the baseline FINDRISC value was associated with diabetes risk among the control group participants only, indicating that the intensive lifestyle intervention given to the intervention group participants abolished the diabetes risk associated with baseline risk factors. In conclusion, the intensive lifestyle intervention produced long-term beneficial changes in diet, physical activity, body weight, and cardiovascular risk factors, and reduced diabetes risk. Furthermore, the effects of the intervention were sustained after the intervention was discontinued. The FINDRISC proved to be a simple, fast, inexpensive, non-invasive, and reliable tool to identify individuals at high risk of type 2 diabetes. The use of FINDRISC to identify high-risk subjects, followed by lifestyle intervention, provides a feasible scheme in preventing type 2 diabetes, which could be implemented in the primary health care system.

New molecular strategies for prevention of fibroproliferative vascular disease : An experimental approach to restenosis

Vascular intimal hyperplasia is a major complication following angioplasty. The hallmark feature of this disorder is accumulation of dedifferentiated smooth muscle cells (SMCs) to the luminal side of the injured artery, cellular proliferation, migration, and synthesis of extracellular matrix. This finally results in intimal hyperplasia, which is currently considered an untreatable condition. According to current knowledge, a major part of neointimal cells derive from circulating precursor cells. This has outdated the traditional in vitro cell culture methods of studying neointimal cell migration and proliferation using cultured medial SMCs. Somatostatin and some of its analogs with different selectivity for the five somatostatin receptors (sst1 through sst5) have been shown to have vasculoprotective properties in animal studies. However, clinical trials using analogs selective for sst2/sst3/sst5 to prevent restenosis after percutaneous transluminal coronary angioplasty (PTCA) have failed to show any major benefits. Sirolimus is a cell cycle inhibitor that has been suggested to act synergistically with the protein-tyrosine kinase inhibitor imatinib to inhibit intimal hyperplasia in rat already at well-tolerated submaximal oral doses. The mechanisms behind this synergy and its long-term efficacy are not known. The aim of this study was to set up an ex vivo vascular explant culture model to measure neointimal cell activity without excluding the participation of circulating progenitor cells. Furthermore, two novel potential vasculoprotective treatment strategies were evaluated in detail in rat models of intimal hyperplasia and in the ex vivo explant model: sst1/sst4-selective somatostatin receptor analogs and combination treatment with sirolimus and imatinib. This study shows how whole vessel explants can be used to study the kinetics of neointimal cells and their progenitors, and to evaluate the anti-migratory and anti-proliferative properties of potential vasculoprotective compounds. It also shows how the influx of neointimal progenitor cells occurs already during the first days after vascular injury, how the contribution of cell migration is more important in the injury response than cell proliferation, and how the adventitia actively contribute in vascular repair. The vasculoprotective effect of somatostatin is mediated preferentially through sst4, and through inhibition of cell migration rather than of proliferation, which may explain why sst2/sst3/sst5-selective analogs have failed in clinical trials. Furthermore, a brief early oral treatment with the combination of sirolimus and imatinib at submaximal doses results in long-term synergistic suppression of intimal hyperplasia. The synergy is a result of inhibition of post-operative thrombocytosis and leukocytosis, inhibition of neointimal cell migration to the injury-site, and maintenance of cell integrity by inhibition of apoptosis and SMC dedifferentiation. In conclusion, the influx of progenitor cells already during the first days after injury and the high neointimal cell migratory activity underlines the importance of early therapeutic intervention with anti-migratory compounds to prevent neointimal hyperplasia. Sst4-selective analogs and the combination therapy with sirolimus and imatinib represent potential targets for the development of such vasculoprotective therapies.

'A responsible nuclear weapons power' : Nuclear Weapons and Indian Foreign Policy

This thesis examines the interrelationship and dynamics between the Indian United Progressive Alliance government’s foreign policy and its nuclear weapons policy. The purpose of the study is to situate nuclear policy within a foreign policy framework, and the fundamental research problem is thus how does the Indian nuclear policy reflect and respond to the Indian foreign policy? The study examines the intentions in the Indian foreign and nuclear policies, and asks whether these intentions are commensurable or incommensurable. Moreover, the thesis asks whether the UPA government differs from its predecessors, most notably the Bharatiya Janata Party-led National Democratic Alliance government in its foreign and nuclear policies. Answers to these questions are based on the interpretation of political texts and speeches as suggested by Quentin Skinner’s notion of meaning3, what does a writer or speaker mean by what he or she says in a given text, and by J.L. Austin’s speech act theory. This linguistic perspective and the approach of intertextualizing, place the political acts within their contingent intellectual and political contexts. The notion of strategic culture is therefore introduced to provide context for these juxtapositions. The thesis firstly analyses the societal, historical and intellectual context of India’s foreign and nuclear policy. Following from this analysis the thesis then examines the foreign and nuclear policies of Prime Minister Manmo-han Singh’s UPA government. This analysis focuses on the texts, speeches and statements of Indian authorities between 2004 and 2008. This study forwards the following claims: firstly, the UPA Government conducts a foreign policy that is mainly and explicitly inclusive, open and enhancing, and it conducts a nuclear policy that is mainly and implicitly excluding, closed and protective. Secondly, despite the fact that the notion of military security is widely appreciated and does not, as such, necessarily collide with foreign policy, the UPA Government conducts a nuclear policy that is incommensurable with its foreign policy. Thirdly, the UPA Gov-ernment foreign and nuclear policies are, nevertheless, commensurable re-garding their internal intentions. Finally, the UPA Government is conduct-ing a nuclear policy that is gradually leading India towards having a triad of nuclear weapons with various platforms and device designs and a function-ing and robust command and control system encompassing political and military planning, decision-making and execution. Regarding the question of the possible differences between the UPA and NDA governments this thesis claims that, despite their different ideological roots and orientations in domestic affairs, the Indian National Congress Party conducts, perhaps surprisingly, quite a similar foreign and nuclear policy to the Bharatiya Janata Party.