Reduce Tobacco Smoking Research Articles

Using health promotion approach for increasing knowledge on harms of tobacco smoking and deciding actions to reduce tobacco smoking among undergraduates in Rajarata University of Sri Lanka

Using health promotion approach for increasing knowledge on harms of tobacco smoking and deciding actions to reduce tobacco smoking among undergraduates in Rajarata University of Sri Lanka

Home Smoking Bans and Urinary NNAL Levels to Measure Tobacco Smoke Exposure in Chinese American Household Pairs.

Home smoking bans can reduce tobacco smoke exposure, but little is known about the impact for Chinese American household pairs. In this study of 202 household pairs with low acculturation, 53.9% reported a home smoking ban, 31.7% had inconsistent reports, and 14.4% reported no ban. With decreasing home smoking ban enforcement, more nonsmokers had tobacco smoke exposure (66.1%–86.2%) as measured by the tobacco-specific nitrosamine biomarker urine NNAL (4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol). Despite reported bans, about one-quarter of nonsmokers still reported tobacco smoke exposure at home (23.6%–30%) within the past 2 months and three-quarters reported outdoor exposure. In adjusted regression analyses of geometric mean NNAL ratios, nonsmokers in households with no ban had over two times higher levels than nonsmokers in households with a ban: adjusted log NNAL ratio = 2.70 (95% CI 1.21, 6.03). Higher smoker NNAL level and nonsmoker English fluency were also significantly associated with nonsmoker NNAL levels. Nonsmoker levels in households with an inconsistent ban were not significantly different compared to those with a ban. Although home smoking bans were generally associated with lower NNAL levels, tobacco smoke exposure in this immigrant population with low English proficiency was higher than that of the general population. From a health equity standpoint, there is a need for broader implementation and enforcement of comprehensive smoke-free policies.

Protecting children from tobacco-related harm in private vehicles

Protecting children from tobacco-related harm in private vehicles

Effect of Reaction Time and Hydrothermal Treatment Time on the Textural Properties of SBA-15 Synthesized Using Sodium Silicate as a Silica Source and Its Efficiency for Reducing Tobacco Smoke Toxicity

The synthesis of SBA-15 has been optimized using sodium silicate, an inexpensive precursor of SBA-15. In this work, the influence of synthesis times of the precipitation and the hydrothermal treatment steps, on the textural properties developed as well as for reducing the toxic compounds generated in tobacco smoking, has been studied. The hydrothermal treatment has been proved to be necessary to obtain materials with adequate performance in this particular application. Twenty-four hours of hydrothermal treatment provide materials with the best properties. Although the reaction stage usually involves the mixing of reagents during 24 h, 40 min is enough to obtain a material with stick-like morphology and typical textural properties. Moreover, between 1 and 2 h of reaction time, the material proved to have the best performance for the purpose of reducing the toxicity of the products generated during the tobacco smoking process. These results are of great significance for an eventual scaling up to industrial scale of the SBA-15 manufacturing process. Results of a pilot plant experiment in a batch of 4 kg of SBA-15 are reported.

Public health psychiatry: an idea whose time has come

Public health psychiatry: an idea whose time has come

Protocol for expansion of an existing national monthly survey of smoking behaviour and alcohol use in England to Scotland and Wales: The Smoking and Alcohol Toolkit Study

Background The Smoking and Alcohol Toolkit Study (STS/ATS) in England has delivered timely insights to inform and evaluate strategies aimed at reducing tobacco smoking- and alcohol-related harm. From the end of 2020 until at least 2024 the STS/ATS is expanding to Scotland and Wales to include all constituent nations in Great Britain. Expanding data collection to Scotland and Wales will permit the evaluation of how smoking and alcohol related behaviours respond to divergent policy scenarios across the devolved nations. Methods The STS/ATS consists of monthly cross-sectional household interviews (computer or telephone assisted) of representative samples of adults in Great Britain aged 16+ years. Commencing in October 2020 each month a new sample of approximately 1700 adults in England, 450 adults in Scotland and 300 adults in Wales complete the survey (~n = 29,400 per year). The expansion of the survey to Scotland and Wales has been funded for the collection of at least 48 waves of data across four years. The data collected cover a broad range of smoking and alcohol-related parameters (including but not limited to smoking status, cigarette/nicotine dependence, route to quit smoking, prevalence and frequency of hazardous drinking, attempts and motivation to reduce alcohol consumption, help sought and motives for attempts to reduce alcohol intake) and socio-demographic characteristics (including but not limited to age, gender, region, socio-economic position) and will be reviewed monthly and refined in response to evolving policy needs and public interests. All data analyses will be pre-specified and available on a free online platform. A dedicated website will publish descriptive data on important trends each month. Discussion The Smoking and Alcohol Toolkit Study will provide timely monitoring of smoking and alcohol related behaviours to inform and evaluate national policies across Great Britain.

Protocol for expansion of an existing national monthly survey of smoking behaviour and alcohol use in England to Scotland and Wales: The Smoking and Alcohol Toolkit Study.

Background The Smoking and Alcohol Toolkit Study (STS/ATS) in England has delivered timely insights to inform and evaluate strategies aimed at reducing tobacco smoking- and alcohol-related harm. From the end of 2020 until at least 2024 the STS/ATS is expanding to Scotland and Wales to include all constituent nations in Great Britain. Expanding data collection to Scotland and Wales will permit the evaluation of how smoking and alcohol related behaviours respond to divergent policy scenarios across the devolved nations. Methods The STS/ATS consists of monthly cross-sectional household interviews (computer or telephone assisted) of representative samples of adults in Great Britain aged 16+ years. Commencing in October 2020 each month a new sample of approximately 1700 adults in England, 450 adults in Scotland and 300 adults in Wales complete the survey (~n = 29,400 per year). The expansion of the survey to Scotland and Wales has been funded for the collection of at least 48 waves of data across four years. The data collected cover a broad range of smoking and alcohol-related parameters (including but not limited to smoking status, cigarette/nicotine dependence, route to quit smoking, prevalence and frequency of hazardous drinking, attempts and motivation to reduce alcohol consumption, help sought and motives for attempts to reduce alcohol intake) and socio-demographic characteristics (including but not limited to age, gender, region, socio-economic position) and will be reviewed monthly and refined in response to evolving policy needs and public interests. All data analyses will be pre-specified and available on a free online platform. A dedicated website will publish descriptive data on important trends each month. Discussion The Smoking and Alcohol Toolkit Study will provide timely monitoring of smoking and alcohol related behaviours to inform and evaluate national policies across Great Britain.

Can emotional intelligence training cause a cease in tobacco smoking among school-going adolescents?

ABSTRACT Emotional intelligence training intervention was used to reduce tobacco smoking consumption among school-going adolescents in state of Edo, Nigeria. The pre-test post-test experimental design was observed. While the 90 participants were purposively selected from the schools that were randomly assigned to EIT (45) and control groups (45). Analysis of covariance and independent t-tests were used for data analysis. The emotional intelligence training intervention significantly improved tobacco smoking cessation of school-going adolescents with pre-test and post-test mean scores of 33.12 (33.12%) and 21.25 (21.25%), respectively. The participants exposed to EIT (Mean = 21.25; SD = 2.68) gained more those in the control group (Mean = 42.79; SD = 14.21). The interaction effect of the treatment and sex was also significant. Conclusively, the emotional intelligence training intervention was effective in tobacco smoking cessation among school-going adolescents, though cessation response could be sex-dependent.

Smoking at the workplaces in Italy after the smoking ban in the Lazio Region.

Background:In Italy, an anti-smoking law was issued in 2003, with the aim of reducing tobacco smoking inside public places.Objectives:The aim of the study was to assess the observance of the smoking ban in Italy, during the period 2010-2014, in several workplaces and to evaluate the perception of workers, both smokers and non-smokers, on this issue.Methods:This cross-sectional study analyzed data resulting from a self-administered questionnaires in 59 companies, from several working sectors (transport, healthcare and building), in the Latium Region in Italy.Results:Out of 7200 questionnaires, 6996 were included in the analysis: 43.7% of the employees think that the smoking ban is respected in the workplace; women are more prone to think that the ban is not observed. Smokers tend to perceive the ban to be respected (AOR: 0.69; 95% CI: 0.62-0.77) while non-smokers feel more exposed to second-hand smoke (AOR: 1.57; 95% CI: 1.39-1.77). Workers in intellectual and highly specialized professions (AOR: 1.63; 95% CI: 1.25-2.13), technical professions (AOR: 1.64; 95% CI: 1.28-2.10) and craftsmen, skilled workers and farmers (AOR: 1.42; 95% CI: 1.09-1.85) tend to perceive the smoking ban not to be observed and the last two classes are the ones who feel the most exposed to second-hand smoke (AOR: 6.68; 95% CI: 0.50-0.90; AOR: 0.52; 95% CI: 0.38-0.70).Discussion:The results of this study can be used as a starting point for the implementation of new strategies to reduce tobacco addiction, beginning from the compliance with the ban on smoking in the workplace and the promotion of a healthy lifestyle.

Current Perspectives on Characteristics, Compositions, and Toxicological Effects of E-Cigarettes Containing Tobacco and Menthol/Mint Flavors.

Electronic nicotine delivery systems/devices (ENDS) such as electronic cigarettes (e-cigarettes) have been made available globally, with the intent to reduce tobacco smoking. To make these products more appealing to young adults, many brands have added flavoring agents. However, these flavoring agents are shown to progressively result in lung toxicity when inhaled via e-cigarettes. While recent federal regulations have banned the sale of flavored e-cigarettes other than tobacco or menthol flavors, concerns have been raised about the health effects of even these flavors. In this review, we evaluate the current toxicological data with regard to effects upon exposure in animal models and in vitro cell culture for these popular flavorants. We have tabulated the current e-cigarette products containing these most common flavors (menthol, mint, and tobacco) in the market. We have also indicated the prevalence of tobacco and menthol-flavor use among e-cigarette users and highlighted the possible challenges and benefits that will result from new federal regulations.

T82. THE IMPACT OF SMOKING ON LIFE EXPECTANCY IN PSYCHOTIC DISORDERS, AN ELECTRONIC CASE REGISTER COHORT STUDY

BackgroundSchizophrenia, schizoaffective disorder and bipolar affective disorder are associated with a life expectancy at birth that is 10–20 years shorter than in the general population. The prevalence of cigarette smoking in people with these disorders is very high, but the extent to which this accounts for differences in mortality is unclear. We addressed this issue by examining the effect of smoking on life expectancy and survival in a large electronic healthcare database of patients receiving secondary mental healthcare in South East London.MethodsData on all patients with a diagnosis of schizophrenia, schizoaffective disorder or bipolar affective disorder from 1st January 2007 to 31st December 2018 was obtained. Smoking status was determined using unstructured text data extracted from electronic health records. Chiang’s method of abridged life tables was used to calculate estimates of life expectancy at birth according to gender and most commonly recorded smoking status. Cox proportional hazards models were used to estimate mortality risk and adjusted for a broad range of demographic and clinical variables.Results21,588 patients were included in the study of which 20,155 (93.4%) were classified as either smokers (16,717 [77.4%]) or non-smokers (3,438 (15.9%]). 2,434 (11.3%) participants died by the end of the observation period. In female patients, life expectancy at birth was 67.6 years in current smokers (95% CI: 66.4 to 68.8) and 74.9 years in non-smokers (95% CI: 72.8 to 77.0). In male patients, life expectancy at birth was 63.5 years in current smokers (95% CI: 62.5 to 64.5) and 68.5 years in non-smokers (95% CI: 64.4 to 72.6). Adjusted survival models showed that current smoking was associated with an increased risk of death, in both females (aHR = 1.42; 95% CI: 1.21–1.66) and males (aHR = 1.49; 95% CI: 1.25–1.79).DiscussionSmoking may account for a substantial proportion of the reduced life expectancy in patients with psychotic disorders. Interventions to reduce tobacco smoking in patients with psychosis may therefore improve life expectancy in this group.

Cancer incidence attributable to tobacco smoking in GCC countries in 2018.

INTRODUCTIONThe Gulf Cooperation Council (GCC) member countries include Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates. The current study aims to provide an estimate of the population fractions of cancer cases attributable to tobacco smoking in the GCC countries.METHODSPopulation attributable fraction (PAF) was calculated for cancers that were listed by the International Agency for Research on Cancer (IARC) to have sufficient evidence of causal association. The estimated number of incident cancer cases in GCC countries were retrieved from the IARC GLOBOCAN database. The prevalence estimates of current tobacco smoking among persons aged ≥15 years were obtained from the World Health Organization report on prevalence of tobacco smoking. Relative risk estimates for various cancers were obtained from published meta-analyses. Summary PAFs and cancer cases attributable to tobacco smoking are reported by country, sex, and cancer type.RESULTSTobacco smoking was responsible for 2536 (16.3%) of cancer cases in GCC countries in 2018. It accounted for 22.8% (n=2396) and 2.8% (n=140) of cancer cases among males and females, respectively. Among males, the highest number of cancer incident cases attributable to smoking was lung cancer (807) followed by urinary bladder (328), and colorectal cancer (305). Among females, the highest number of cancer cases attributable to smoking was lung cancer (62) followed by lip and oral cavity (13), and cervical cancer (13).CONCLUSIONSTobacco smoking accounted for a large portion of cancer cases attributable to preventable risk factors in GCC countries. Preventive efforts focusing on reducing tobacco smoking should be a high priority in GCC countries.

Co-use and Mixing Tobacco With Cannabis Among Ontario Adults.

The legalization of nonmedical cannabis in 2018 may have important implications for tobacco use in Canada. There is a risk of renormalizing tobacco use with co-use of tobacco and cannabis introducing nontobacco users to tobacco. Co-use is the use of both substances by the same individual at the same time or on different occasions, as well as mixed together. This study assessed the prevalence of co-use and mixing of tobacco and cannabis among Ontario adults and the characteristics of the users. Data from the 1996 to 2017 cycles of the Centre for Addiction and Mental Health Monitor (n = 4481) were used to examine trends in prevalence and the proportion of Ontario adults co-using and mixing tobacco and cannabis. Logistic regression was used to study associations between user characteristics and co-use and mixing. Co-use of cigarettes and cannabis among cannabis users declined from 59.8% in 1996 to 41.7% in 2017. Past-year e-cigarette use was the only predictor of co-use. From 2015 to 2017, 31.1% (95% confidence interval 27.0, 35.9) of Ontario adults who used cannabis reported mixing it with tobacco in the past year. Being white, past-year e-cigarette use, having moderate or high nicotine dependence, and having moderate or high risk for cannabis problems were significant predictors of mixing among cannabis users. Given the well-established negative health effects associated with tobacco use, alongside a growing evidence base for negative health effects of cannabis smoking, co-use and mixing could pose a considerable public health concern in the context of legalization. Considerable effort has been expended to reduce tobacco smoking. However, current efforts to reduce tobacco smoking may be diminished since this study found the prevalence of mixing tobacco and cannabis among cannabis users in Ontario to be higher than expected. Mixing tobacco and cannabis may introduce nontobacco smokers to tobacco, exposing them to health risks associated with both cannabis and tobacco smoke. Therefore, there is a need to monitor changes in tobacco use and understanding implications for tobacco control and cessation programs within the changing environment of cannabis legalization in Canada and other jurisdictions.

Reducing Tobacco Smoke Exposure in High-Risk Infants: A Randomized, Controlled Trial

To evaluate a hospital-initiated intervention to reduce tobacco smoke exposure in infants in the neonatal intensive care unit. A randomized, controlled trial compared motivational interviewing plus financial incentives with conventional care on infant urine cotinine at 1 and 4months' follow-up. Mothers of infants in the neonatal intensive care unit (N=360) who reported a smoker living in the home were enrolled. Motivational interviewing sessions were delivered in both the hospital and the home. Financial incentives followed session attendance and negative infant cotinine tests postdischarge. The intervention effect on infant cotinine was not significant, except among mothers who reported high baseline readiness/ability to protect their infant (P≤.01) and mothers who completed the study within 6months postdischarge (per protocol; P≤.05). Fewer mothers in the motivational interviewing plus financial incentives condition were smoking postdischarge (P≤.01). More mothers in the motivational interviewing plus financial incentives group reported a total home and car smoking ban at follow-up (P≤.05). Motivational interviewing combined with financial incentives reduced infant tobacco smoke exposure in a subset of women who were ready/able to protect their infant. The intervention also resulted in less maternal smoking postpartum. More robust interventions that include maternal and partner/household smoking cessation are likely needed to reduce the costly effects of tobacco smoke exposure on children and their families. ClinicalTrials.gov: NCT01726062.

Associations between personality and uptake of tobacco smoking: Do they differ across adolescence?

Tobacco use is one of the leading causes of death globally, yet it is entirely preventable. Tobacco smoking typically begins in adolescence, and thus efforts to intervene early are vital. Personality has been identified as a risk factor for smoking in adolescence. The current study aimed to examine whether associations between personality traits (impulsivity, sensation-seeking, anxiety sensitivity and hopelessness) and new onset tobacco smoking differ across adolescence. At baseline, 527 secondary-school students (mean age 13 years) completed a validated personality questionnaire and were surveyed on recent tobacco smoking. Participants were followed-up at 12-, 24- and 36-months. Logistic regression was conducted to examine prospective associations between the four personality types and tobacco smoking at each follow-up. Results revealed age-related differences in the associations between personality and smoking in adolescence. Baseline sensation-seeking was significantly associated with new onset tobacco smoking at age 14; baseline impulsivity was significantly associated with new onset tobacco smoking at age 15; and baseline hopelessness was significantly associated with new onset tobacco smoking at age 16. This study extends knowledge by demonstrating age-specific effects on the association between personality and smoking. This has important implications for prevention and could inform the development of tailored smoking interventions to be delivered at different ages. Future research will examine personality-targeted intervention in reducing tobacco smoking in Australian adolescents across different ages.

Knowledge and use of e-cigarettes among nursing students: results from a cross-sectional survey in north-eastern Italy

BackgroundData on electronic cigarette (e-cigarette) use among health professional students, who can play a central role in promoting healthy habits and smoking cessation, are sparse. Moreover, the association between e-cigarettes and smoking habits is still debated. The present study aimed to investigate the diffusion of e-cigarette use among nursing students in north-eastern Italy and explore its association with tobacco smoking.MethodsIn 2015, a questionnaire focused on e-cigarette use and tobacco smoking habits was anonymously administered to 2020 students attending nursing courses held by Verona University in 5 different centres. Of these students, 1463 (72.4%) answered the questionnaire. The influence of e-cigarette ever use on both tobacco smoking initiation in all subjects and smoking cessation among ever smokers was investigated by multivariable logistic models.ResultsMost responders were female (77.1%), and the mean (SD) age was 23.2 (4.2) years. Nearly all students (94.7%) had heard about e-cigarettes. Approximately one-third (30.3, 95% CI 27.9–32.7%) had ever used e-cigarettes, but only 2.1% (1.5–3.0%) had used e-cigarettes in the last month. Very few (2.1%) of those responders who had never used e-cigarettes were willing to try them. Prevalence values were much higher for tobacco smoking: 40.9% of responders reported being current tobacco smokers, and 10.1% reported being past smokers. Ever use and current use of e-cigarettes were reported by 57.2 and 4.4% of current tobacco smokers and by 12.0 and 0.6% of never or past smokers, respectively (p < 0.001). In multivariable analysis, students who ever used e-cigarettes had 13 times greater odds of being an ever tobacco smoker than never users, whereas they had three times lower odds of being a former smoker.Only 26 students were currently using both electronic and tobacco cigarettes, and most declared that they used e-cigarettes to stop or reduce tobacco smoking. Of note, only three students reported that they had completely stopped smoking thanks to e-cigarette use.ConclusionUse of e-cigarettes seemed to be rather rare among Italian nursing students and was mainly restricted to current smokers. E-cigarette use was not associated with smoking cessation in nursing students.

E-Cigarette Use, Its Impact on Tobacco Smoking and the Intention to Quit

E-cigarettes have rapidly gained worldwide popularity. Since its use still poses a health risk to the users, it is important to assess their intention to quit this habit. This study aimed to determine the characteristics of e-cigarette use, its effect on cigarette smoking and users’ intention to quit vaping and smoking. A total of 377 e-cigarette users were recruited from three vape retail stores in Bandar Baru Bangi, Selangor. E-cigarette usage pattern, tobacco cigarette consumption and their intention to quit were assessed using a self-administered questionnaire. Most (70%) participants were e-cigarettes only users while 30% were dual users. The median duration of e-cigarette use was 2 (IQR 2) years. Almost all (98.4%) participants used third-generation devices and majority (63.7%) preferred liquid containing 6mg nicotine. About 92% participants, especially heavy smokers, smoked fewer tobacco cigarettes after initiating e-cigarette. Majority (79.6%) of dual users also had reduction in tobacco cigarette consumption with a median current consumption of 5 (IQR 5.0) cigarettes per day. Most (87%) e-cigarette users intend to quit the habit someday. However, many (63.1%) were in the pre-contemplation stage. E-cigarette users of less than 2 years duration tend to have the intention to quit compared to users of more than 2 years (p=0.005). In conclusion, there was more e-cigarette only users than the dual users. E-cigarette use could significantly reduce tobacco smoking, especially among heavy smokers. Most e-cigarette users had the intention to quit vaping but not in the near future and longer e-cigarette use may deter their intention to quit.

P420 Reducing tobacco smoke exposure in paediatric cystic fibrosis: a qualitative examination of caregivers' and clinicians perspectives

P420 Reducing tobacco smoke exposure in paediatric cystic fibrosis: a qualitative examination of caregivers' and clinicians perspectives

Testing the PPAR hypothesis of tobacco use disorder in humans: A randomized trial of the impact of gemfibrozil (a partial PPARα agonist) in smokers.

Previous pre-clinical studies demonstrated a promising role of alpha-type peroxisome proliferator-activated receptors (PPARα) agonists in decreasing nicotine self-administration and nicotine-seeking behavior in animals. Our goal was to investigate the potential of gemfibrozil, a PPARα agonist, on reducing tobacco smoking in humans. Methods: This was a double-blind, placebo-controlled, crossover study evaluating the effects of gemfibrozil (1200 mg/day) on smoking in 27 treatment-seeking smokers. The study had two 2-week phases separated by a washout period of at least 1 week. In each phase and after 1 week on medication, participants underwent a lab session where cue reactivity and forced choice paradigms were conducted. Physiological responses and self-reported craving were monitored during the presentation of smoking and neutral cues. In addition, two types of cigarettes were used in the forced choice paradigms: the Nicotinized cigarettes (Nic) and the Denicotinized cigarettes (Denic). The goal of the forced choice was to calculate the percentage of choice of Nic cigarettes while taking gemfibrozil or placebo. The number of quit days was calculated during the two quit attempts weeks (one while taking gemfibrozil and one while taking placebo) of the study. Results: There were no significant differences between gemfibrozil and placebo groups in the percentage of choice of Nic cigarettes, the cue-reactivity (both physiological and subjective measures), or in the number of days of abstinence. Conclusions: Although preclinical studies with PPAR α agonists showed promising results, this preliminary study did not demonstrate positive effect of gemfibrozil on tobacco use and cessation indices.

Health needs in local government policies in Poland in the context ofanti-smoking health policy programs

According to the World Health Organization (WHO), every year tobacco smoking kills around 5.4 million people worldwide. Tobacco smoking is a major risk factor for cardiovascular diseases, respiratory diseases and cancer. In Poland, an average of 67,000 people die every year on account of smoking. The aim of the study was to evaluate the health security guaranteed by local governments based on an analysis of health policy programs associated with tobacco consumption, which were conducted in Poland from 2009 to 2014 by local governments. The study was based on desk research. The data was sourced from the annual reports submitted to the Minister of Health, concerning the health policy programs which were carried out. The analysis covered programs which name, objective or description of tasks indicated that they concerned tobacco smoking. The largest number of programs was completed in the West Pomeranian, Warmian-Masurian and Masovian voivodeships. The smallest number of programs were completed in Kuyavian-Pomeranian, Łódź and Opole voivodeships. The greatest number of programs were carried out by municipalities, followed by counties and county towns, and finally by self-governments of the voivodeships. The number of preventive programs was significantly greater than the number of other types of programs. The majority of programs were aimed at children; there were fewer programs dedicated to adults. The expenditure on the programs was the highest in self-governments of the voivodeships, while the lowest was in municipalities. The steady growth in the number of anti-smoking programs completed 2009-2014 was one of the factors that reduced tobacco smoking. In view of the mortality rates due to cardiovascular diseases, the inhabitants of Lublin and Warmian-Masurian voivodeships had their health needs addressed most efficiently. In the case of mortality rates due to tracheal, bronchial and lung cancer, the health needs of the inhabitants of Warmian-Masurian and West Pomeranian voivodeships were addressed most efficiently.