The danger of second-hand smoke

Second-hand smoke is a mixture of the smoke from the burning tip of a cigarette and the smoke exhaled by a smoker. When second-hand smoke contaminates the air, especially in enclosed spaces, it is inhaled by everyone, exposing both smokers and non-smokers to its harmful effects. It causes lung cancer in non-smokers and increases the risk of coronary heart disease.

Although the majority of smokers are men, many women and children are affected by their second-hand smoke. Worldwide, second-hand smoke causes an estimated 600 000 premature deaths a year, the majority (64%) among women. In the Eastern Mediterranean Region 38% of students aged 13–15 are exposed to second-hand smoke at home, and in many countries only around a quarter of homes are smoke-free. Only around 50% of schools ban the use of tobacco products by teachers.

The harm to health from second-hand smoke

There are over 4000 known chemicals in tobacco smoke, many of which are harmful, with at least 40 that cause cancer. It also includes large quantities of carbon monoxide, a gas that hinders the blood’s ability to carry oxygen to vital organs such as the heart and brain, and substances that contribute to heart disease and stroke. Exposure to second-hand smoke has both immediate and long term effects, including the following:

Immediate effects include irritation of the eyes, nose, throat and lungs, and sometimes headaches, nausea and dizziness. Exposure can also trigger asthma attacks.

Long-term exposure to second-hand smoke causes lung cancer, coronary heart disease and cardiac death. Non-smokers who live with smokers are at increased risk of smoking-related illnesses. The risk of coronary heart disease is increased by 25%–30% and lung cancer by 20%–30%.

Second-hand smoke risks for children

Exposure to second-hand smoke during pregnancy is associated with decreased birth weight. This can lead to increased risk of developing medical problems and learning difficulties. Parents who smoke may harm their infant children by increasing the risk of sudden infant death syndrome, reduced physical development and childhood cancer.

Children are particularly vulnerable to second-hand smoke due to their smaller lungs and less developed immune systems. Exposure to second-hand smoke in children results in respiratory illnesses, chronic respiratory symptoms (such as asthma), ear infections and reduced lung function. Children of smoking mothers have more episodes of respiratory illness. There is a clear link between smoking in the home and the hospital admission of children for pneumonia and bronchitis.

Protection against second-hand smoke

Non-smokers need to be protected from second-hand smoke exposure within the home, at school and in the workplace. Women and children often do not have the power to negotiate smoke-free spaces, even within their own homes. Some workers are obliged to spend most of their work time in a health-threatening environment.

Protection can be achieved through smoking bans and by smokers taking responsibility for not exposing others to their second-hand smoke. Smoke-free legislation is very popular wherever it is enacted, with support for tobacco control measures usually increasing after implementation. Smoke-free workplaces help to motivate smokers to quit smoking and reduce tobacco consumption by 4%–10%. Smoke-free policies also help prevent people, especially the young, from starting to smoke.

The tobacco industry has tried to argue that smoking bans infringe smokers’ rights and freedom of choice, but no one has the right to harm others. Smoke-free laws do not infringe anyone’s rights and are simply there to protect people’s health by regulating where to smoke and where not to smoke.

Best practices and the way forward

Article 8 of the WHO Framework Convention on Tobacco Control addresses protection from exposure to tobacco smoke. It stipulates that all people need to be protected from second-hand smoke through the adoption and implementation of legislative and other measures to provide protection from exposure to tobacco smoke in indoor workplaces, public places and public transport.

It is important to remember the following:

There is no safe level of exposure to second-hand smoke.

Non-smokers, including women and children, have a right to breathe tobacco-free clean air.

Ventilation or designated smoking-rooms do not offer effective protection.

All indoor workplaces, public transport, schools and health services should be smoke-free.

People need to be better informed of the hazards of second-hand smoke to themselves, foetuses, children and other family members.

The Regional Director made clear his commitment to dynamic, effective and transparent management, to building a coordinated one-WHO response to global and regional health challenges, and to intersectoral approaches to major public health issues. A number of challenges and priorities were identified for action to enhance management processes, efficiency and transparency.

Programmes and priority-setting

Regional strategic directions: based on the in depth analysis of the challenges facing health development in the Region, five technical areas were identified in which WHO’s capacity will be increased and technical support to Member States Strengthened, including: health system strengthening; maternal, reproductive and child health and nutrition; noncommunicable diseases; communicable diseases; and emergency preparedness and response. These priorities are consistent with the priorities recommended subsequently by the Executive Board, and endorsed by Member States, for the draft Twelfth General Programme of Work for 2014–2019.

Specific needs of Member States: While there have been advances in the field of health in a number of Member States in recent years, wide disparities remain between and within countries in regard to specific health challenges. Countries also differ widely in population health outcomes, health system performance and level of health expenditure. This means that strategies must be tailored to the needs of countries at both the regional and country levels. This will allow for more targeted technical cooperation and the establishment of networks between countries with similar challenges and experiences.

Technical support to Member States: Strengthening the technical competence of WHO and expanding the capacity to deliver first-class technical support is a key priority of the reform process. Current capacity has been reviewed and adjustments to existing practices are currently under development. Technical departments have already initiated the establishment of rosters of well qualified experts in each key technical area who are selected and retained in advance for deployment to Member States as and when required. The outcome of technical support to Member States will be evaluated regularly and jointly by WHO and the recipient Ministry of Health.

Programming, results framework and standardized planning: The twelfth general programme of work and the programme budget 2014–15 established the programming and results framework, which will be used as the basis for planning and performance monitoring. This was built around six categories that replaced the current 13 strategic objectives: 1) communicable diseases; 2) noncommunicable diseases; 3) promoting health throughout the life-course; 4) health systems; 5) prepardness, surveillance and response; 6) corporate services and enabling functions. After a clear priority setting at country level, planning will essentially address country priorities as well as normative work, taking into consideration regional and global resolutions and recommendations from other advisory bodies such as the Technical Advisory Committee (TAC) that replaced the Regional Consultative Committee (RCC). The Regional Office has adopted an important principle which is to reduce the fragmentation of plans and focus action on fewer programme areas and deliverables.

Country cooperation strategy documents: The process of development of country cooperation strategy (CCS) documents involves extensive consultations across the Secretariat, with the country’s government, and with bilateral and multilateral agencies, civil society, academic institutions, collaborating centres and the private sector. However, there are currently significant gaps in the way the CCS is developed, and the quality of the process and of the outcome varies from one country to another. An in-depth analysis of the current experience is being conducted, and updated guidance on the CCS process, reflecting the importance of the document as an essential tool for the implementation of WHO reform, will be developed.

Within the same spirit the Joint Programme Review and Planning Mission (JPRM) process is also being reviewed for streamlining and refocusing the country programmes on key priorities. A new approach will be implemented for the biennium 2014–2015 taking into consideration the new programme budget structure, the recommendation of the Regional Committee, as well the regional vision and global categories mentioned above.

Decentralization of services: To ensure that services provided at country level are optimal, activities within the Regional Office that are of similar nature have been grouped, with the aim of considering their eventual relocation to more cost-effective locations. One example of this approach is the consolidation of all environmental health projects and activities within the Regional Centre for Environmental Health Activities in Amman, Jordan.

Governance

WHO’s reform programme seeks to attract more active engagement and more informed participation by all Member States in governance processes, and to rebalance the way in which Member States exercise their role as informed and active participants in the work of the governing bodies. Based on guidance from Member States in January 2012, work in the area of governance focuses on four main priorities: a) more rational scheduling, alignment and harmonization of governance processes; b) strengthened oversight; c) greater strategic decision-making by governing bodies; and d) more effective engagement with other stakeholders. The reform addresses the need for improved linkages between regional committees and global governing bodies, as well as standardizing the practices of the six regional committees. Initiatives have included:

• high-level meetings for Member States’ representatives and permanent missions in Geneva prior to each major meeting of the WHO governing bodies (World Health Assembly, Executive Board);
• concise and timely briefings to representatives to global governing bodies’ meetings to facilitate health policy decision-making processes;
• video and teleconferences with representatives on important issues of concern to Member States whenever the situation warrants it;
• revised rules of procedure of the Regional Committee to ensure alignment with best practice in the Organization;
• a regional Technical Advisory Committee to provide advice to the Regional Director on matters relating to strengthening technical cooperation among and between Member States of the Region, providing support in evaluating programmes and assisting with resource mobilization, with a planned meeting in April of each year.

Management

Stronger technical, normative and policy support for all Member States is a key area in WHO reform. The area of management aims to achieve six main objectives: a) effective technical and policy support for all Member States; b) staffing matched to needs at all levels; c) a financing mechanism that respects agreed priorities; d) effective systems for accountability and risk management; e) a culture of evaluation; and f) strategic communications. In this area, the secretariat embarked on the following initiatives.

Realignment of the Regional Office structure: Two new departments were created within the Regional Office – Information, Evidence and Research and Noncommunicable Diseases and Mental Health – to meet the health challenges facing the Region, ensure focus is placed on key programme areas, and improve synergies across programmatic areas. The units concerned with communications, partnerships and resource mobilization were consolidated for greater coherence and efficiency. A new strategy for this important area is being developed in collaboration with key stakeholders, and in consultation with headquarters and other regional offices. This realignment of structure with current needs will lead to a more streamlined distribution of the workforce.

Resource mobilization: WHO is actively taking part in global efforts to secure increased feasibility and predictability of financing, with a focus on regional donors and partners. Mobilization of resources from within the Region is minimal compared with other WHO regions. There is currently no operational resource mobilization strategy. The unit responsible for resource mobilization has been strengthened and a comprehensive resource mobilization plan will be developed in 2013.

WHO in the Region is committed to building stronger and more effective engagement with regional stakeholders, nongovernmental organizations, academia and the private sector, including the Organization of the Islamic Conference, Islamic Development Bank, African Development Bank, Gulf Cooperation Council, League of Arab States, and United Nations regional bodies. Emphasis will also be placed on coordination with global health initiatives and with development partners at the country level. Initial steps have been undertaken by the Regional Office in this direction in the past few months.

Strengthening country offices: Reports by internal and external auditors, as well as clear observations from Member States have shown the need for increased support to countries through more efficient managerial processes and improvements in the way challenges are addressed in the operating environment. Specific gaps have been identified in leadership, in quality of technical support provided to countries, and in the linkage between the CCS and operational planning. Other significant challenges concern financing, monitoring and the maintaining of an adequate control environment. The planning process and tools that guide WHO’s technical activities in Member States need to be more efficient and effective, and should aim to ensure that there is a clear connection between the needs of Member States, the CCS, and the funding and activities planned by WHO in a given budgetary cycle.

Staffing: Staff selection methods are being revised through the implementation of a recruitment process based on generic, rather than customized, post descriptions. This is intended to lead to a more transparent and efficient recruitment process. Improvements in staff development activities are intended to strengthen country offices and will prepare national staff to be more competitive when applying for international positions in the Organization. The rotation of staff between country offices and the Regional Office has been initiated and will address the deteriorating effect of staff remaining in one duty station for too long. Performance management has been assigned a higher priority and will be closely linked to staff development to ensure that WHO staff meet the expectations set by Member States.

Evaluation: Internal control mechanisms have been strengthened through the introduction of quality assurance processes and a regional compliance function. An independent evaluation of key programmes has been initiated and financial and management reviews of key offices have been launched to complement routine internal and external audits. A risk management framework has been introduced with input from country offices and programmes across the Region to allow for the identification of strategic and operational risks and mitigation measures. A compliance committee has been established to enhance the Organization’s control environment and to mitigate the determined risks. Compliance reviews were conducted on some critical areas such as agreements for performance of work and travel. The level of compliance with the established travel policies has improved and further improvement is expected by the end of 2014.