Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 108 num. 3 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>Intellectual disability in South Africa: Addressing a crisis in mental health services</b>]]> <![CDATA[<b>Medicolegal storm threatening maternal and child healthcare services</b>]]> <![CDATA[<b>Celebrating 50 years of heart transplant surgery: A missed opportunity to honour Hamilton Naki</b>]]> <![CDATA[<b>30 days in medicine</b>]]> <![CDATA[<b>Intellectual disability in the Esidimeni tragedy: Silent deaths</b>]]> <![CDATA[<b>The Life Esidimeni tragedy: The courts are also to blame</b>]]> <![CDATA[<b>The Life Esidimeni tragedy: Some ethical transgressions</b>]]> <![CDATA[<b>Bleeding disorders (part 2)</b>]]> <![CDATA[<b>Acquired bleeding disorders</b>]]> Bleeding disorders are divided into two broad categories, i.e. inherited, discussed in part 1 of this CME series, and acquired, which is the subject of discussion in the current issue. In contrast to inherited haemorrhagic disorders, where generally a single haemostatic abnormality is found, multiple haemostatic defects are commonly present in acquired haemorrhagic diseases. Bleeding is often a presenting manifestation of systemic disease and requires a multidisciplinary team approach. Iatrogenic causes of abnormal haemostasis are of particular importance to the emergency physician. This CME article aims to provide an approach to the diagnosis and management of acquired bleeding disorders encountered in general practice. <![CDATA[<b>Regulating the South African sport supplement industry: 'Whey' overdue</b>]]> The South African sport supplement industry has experienced rapid growth in recent years. Despite the massive market demand, this industry remains poorly regulated. From raw ingredient contamination to label compliance discrepancies, the sport supplement industry is an area of growing concern and warrants further public debate. <![CDATA[<b>Medical device regulation in South Africa: The Medicines and Related Substances Amendment Act 14 of 2015</b>]]> The Medicines and Related Substances Amendment Act 14 of 2015 has brought significant changes in the regulation of medical devices in South Africa (SA). The highlights include the establishment of a regulatory authority - the SA Health Products Regulatory Authority - the introduction of a tier-based licensing and registration system, and the restriction of bonusing and sampling for the sale of medical devices. The enactment of the new regulations is a positive development for the SA medical device industry. However, the impact depends on the implementation of these regulations. Conditions that will support the success of the regulations include creating a critical mass of skilled personnel and measures that ensure timely registration. SA can learn from the experiences and practices of other countries that have introduced medical device regulations in recent years. <![CDATA[<b>Maternal near-miss audit in the Metro West maternity service, Cape Town, South Africa: A retrospective observational study</b>]]> BACKGROUND. A maternal near-miss is defined as a life-threatening pregnancy-related complication where the woman survives. The World Health Organization (WHO) has produced a tool for identifying near-misses according to criteria that include the occurrence of a severe maternal complication together with organ dysfunction and/or specified critical interventions. Maternal deaths have been audited in the public sector Metro West maternity service in Cape Town, South Africa, for many years, but there has been no monitoring of near-misses. OBJECTIVES. To measure the near-miss ratio (NMR), maternal mortality ratio (MMR) and mortality index (MI), and to investigate the near-miss cases. METHODS. A retrospective observational study conducted during 6 months in 2014 identified and analysed all near-miss cases and maternal deaths in Metro West, using the WHO criteria. RESULTS. From a total of 19 222 live births, 112 near-misses and 13 maternal deaths were identified. The MMR was 67.6 per 100 000 live births and the NMR 5.83 per 1 000 live births. The maternal near-miss/maternal death ratio was 8.6:1 and the MI 10.4%. The major causes of near-miss were hypertension (n=50, 44.6%), haemorrhage (n=38, 33.9%) and puerperal sepsis (n=13, 11.6%). The first two conditions both had very low MIs (1.9% and 0%, respectively), whereas the figure for puerperal sepsis was 18.9%. Less common near-miss causes were medical/surgical conditions (n=7, 6.3%), non-pregnancy-related infections (n=2, 1.8%) and acute collapse (n=2, 1.8%), with higher MIs (33.3%, 66.7% and 33.3%, respectively). Critical interventions included massive blood transfusion (34.8%), ventilation (40.2%) and hysterectomy (30.4%). Considering health system factors, 63 near-misses (56.3%) initially occurred at a primary care facility, and the patients were all referred to the tertiary hospital; 38 (33.9%) occurred at a secondary hospital, and 11 (9.8%) at the tertiary hospital. Analysis of avoidable factors identified lack of antenatal clinic attendance (11.6%), inter-facility transport problems (6.3%) and health provider-related factors (25.9% at the primary level of care, 38.2% at secondary level and 7.1% at tertiary level). CONCLUSIONS. The NMR and MMR for Metro West were lower than in other developing countries, but higher than in high-income countries. The MI was low for direct obstetric conditions (hypertension, haemorrhage and puerperal sepsis), reflecting good quality of care and referral mechanisms for these conditions. The MIs for non-pregnancy-related infections, medical/surgical conditions and acute collapse were higher, suggesting that medical problems need more focused attention. <![CDATA[<b>Mental illness in the Western Cape Province, South Africa: A review of the burden of disease and healthcare interventions</b>]]> Neuropsychiatric disorders were ranked third as contributors to disability-adjusted life-years in South Africa (SA). Despite this high morbidity, mental health is often overlooked on the public health agenda. This article reviews evidence on the burden of mental illness in the Western Cape Province of SA, as well as current provincial interventions to decrease the burden of mental illness. Available evidence supports the need for improved integration of mental health services in primary healthcare and strengthening of community services. Challenges include a lack of capacity due to staff shortages and inadequate availability and allocation of resources. Evidence from large epidemiological studies to quantify the burden of disease as well as cost-effectiveness studies of interventions are required to successfully plan and implement interventions. Similar reviews may provide a national overview of mental health issues as well as allow improvement through better understanding of research and best practices in various provinces. <![CDATA[<b>A longitudinal perspective on violence in the lives of South African children from the Birth to Twenty Plus cohort study in Johannesburg-Soweto</b>]]> BACKGROUND. Violence against children is a significant cause of personal suffering and long-term ill health, poor psychological adjustment, and a range of social difficulties, including adverse effects intergenerationally. OBJECTIVES. Using a large corpus of longitudinal data collected in the Birth to Twenty Plus cohort, to give an overview of exposure to and experience of violence, as well as perpetration of violence, across childhood, reported contemporaneously by several informants. This overcomes limitations of retrospectively recalled information collected from one person at one point in time. METHODS. We identified 280 data points relating to exposure to and perpetration of violence in 14 of the 21 waves of data collection from birth to 22 years of age. Data were classified into four developmental stages (preschool, primary school years, adolescence and young adulthood) and seven categories (exposure to violence in the community, home and school; exposure to peer violence; being a victim of violence, excluding sexual violence; sexual violence; and perpetration of violence). Both descriptive and inferential statistics were employed to analyse the data. RESULTS. Over the past two decades, only 1% of the sample had not been exposed to or experienced violence in their home, school and/or community. Two-thirds of children of schoolgoing age were reported as having been exposed to community violence, and more than half of all children to violence in their home. Reports of sexual violence increased from 10% among primary school-aged children to ~30% among adolescents and young adults. Over the course of their lives, ~40% of children were reported as having been exposed to or being victims of five or six of the categories of violence coded in this analysis. High levels of violence perpetration were reported across childhood. Age and gender differences in exposure to and experience and perpetration of violence were evident, and all categories of violence were more prevalent among poorer and more disadvantaged groups. CONCLUSIONS. Very high levels of violence were reported in all the settings of urban South African children's lives: home, community, school, among peers and in their intimate relationships. Children and youth were also reported to perpetrate high levels of violence. The personal and social costs of violence are very high, resulting in major public health problems due to its avoidable effects on short- and long-term mental and physical health and social adjustment, and intergenerationally. <![CDATA[<b>Ethnopharmacological use of potassium permanganate in South African traditional medicine</b>]]> BACKGROUND. Potassium permanganate (KMnO4), which is widely available, is often used by traditional health practitioners (THPs) in South Africa (SA) without taking its potentially harmful properties into account. The crystalline KMnO4 salt is sold at traditional medicine markets and shops throughout SA. However, to date, traditional uses of KMnO4 remain undocumented. OBJECTIVE. To describe KMnO4 use by THPs in KwaZulu-Natal, SA. METHODS. This sub-study is part of a larger study investigating substances used in SA traditional medicine that are collectively known as imikhando in isiZulu - literally translated as 'ore'. THPs (N=201) were interviewed in the local language (isiZulu) by trained interviewers. Information on the reasons for using/not using KMnO4, the source of information on its use and modes of administration were collected. RESULTS. KMnO4 was used as a constituent of traditional medicine by 158 (79%) THPs. Their knowledge of KMnO4 use was acquired predominantly from fellow THPs (n=134; 85%). Reasons for use included skin rash or wounds (n=99, 63%) and to treat aches, pains and swelling (n=74; 47%). The main modes of administration were in the bath (n=94; 60%), orally (n=67; 42%) and in herbal compresses (n=66; 42%). The principal reason of the 43 THPs for not administering KMnO4 was not knowing how to use it (n=29; 71%). CONCLUSIONS. This study has identified traditional medicine users at risk of manganese toxicity owing to commonly used sociocultural practices. In particular, reports of oral ingestion and use in enemas are cause for concern. This public health issue needs regulatory measures and education programmes to enlighten the population against possible harm caused by KMnO4 exposure. <![CDATA[<b>A needs-based approach to equitable allocation of district primary healthcare expenditure in North West Province, South Africa</b>]]> BACKGROUND. Inequity in resource allocation and expenditure exists in the South African (SA) health system at provincial and district level. Needs-based resource allocation has been utilised in developed and developing countries to promote equity. OBJECTIVES. To assess current spending patterns on primary healthcare (PHC)-level care at district level, and ultimately to promote equity in district PHC spending using a needs-based resource allocation approach in North West Province, SA. METHODS. Data on PHC expenditure in 2013/14 were derived from the Vulindlela system. Data on key indicators of need for health services in each district were collated from various sources published online. Alternative needs-based formulae were calculated, and sensitivity analyses were conducted to assess the impact of key assumptions. RESULTS. The analysis produced four possible needs-based formulae. The districts of Bojanala and Dr Kenneth Kaunda in North West are relatively under-resourced, while Ngaka Moderi Molema and Dr Ruth Segomotsi Mompati are relatively over-resourced. The results suggest that, in moving towards each district's equity target, a relative redistribution of resources should be undertaken over several years, preferably in the context of an annual increase in the real overall provincial PHC health budget, to avoid any absolute budget cuts for relatively over-resourced districts. CONCLUSIONS. Inequity in PHC expenditure exists between the districts of North West. A needs-based resource allocation approach can promote equity across districts. Any formula selected by the Department of Health will need to be refined over time as more up-to-date and accurate data become available. It is recommended that for the initial phase the formula be based on population size, which will need to be updated at regular intervals. The same would apply to other indicators of need selected for the formula. Important areas for refining the formula over time are: (i) estimating the differential cost of providing care in rural v. urban areas, as assumptions were used in this study; and (ii) identifying a more comprehensive burden of disease indicator for which data are available at district level in the province. <![CDATA[<b>A retrospective time trend study of firearm and non-firearm homicide in Cape Town from 1994 to 2013</b>]]> BACKGROUND. Gunshot injuries from interpersonal violence are a major cause of mortality. In South Africa (SA), the Firearms Control Act of 2000 sought to address firearm violence by removing illegally owned firearms from circulation, stricter regulation of legally owned firearms, and stricter licensing requirements. Over the last few years, varied implementation of the Act and police corruption have increased firearm availability. OBJECTIVES. To investigate whether changes in firearm availability in SA were associated with changes in firearm homicide rates. METHODS. This was a retrospective time trend study (1994 - 2013) using postmortem data. Time trends of firearm and non-firearm homicide rates were analysed with generalised linear models. Distinct time periods for temporal trends were assigned based on a priori assumptions regarding changes in the availability of firearms. RESULTS. Firearm and non-firearm homicide rates adjusted for age, sex and race exhibited different temporal trends. Non-firearm homicide rates either decreased or remained stable over the entire period. Firearm homicide increased at 13% annually from 1994 through 2000, and decreased by 15% from 2003 through 2006, corresponding with changes in firearm availability in 2001, 2003, 2007 and 2011. A 21% annual increase in firearm homicide after 2010 coincided with police fast-tracking new firearm licence applications. Cape Town's coloured population experienced a significantly greater increase than other population groups following additional exposure to illegal firearms from 2007. CONCLUSIONS. The strong association between firearm availability and homicide, and the reversal of a decreasing firearm homicide trend during a period of lax enforcement, provide further support for the association between reduced firearm homicide and stricter regulation. <![CDATA[<b>An audit of ingested and aspirated foreign bodies in children at a university hospital in South Africa: The Pietermaritzburg experience</b>]]> BACKGROUND. The ingestion or aspiration of foreign bodies (FBs) by children is a common problem around the world. Our centre in Pietermaritzburg, South Africa, has a dedicated paediatric surgical service, and all patients with an ingested or aspirated FB are managed under the direct care of a paediatric surgeon. OBJECTIVES. To review our centre's experience with this problem by means of a retrospective audit and use the data to develop and refine appropriate local management guidelines. METHODS. Grey's Hospital has a hybrid electronic medical registry (HEMR) that captures patient data on admission, after a procedure and on discharge. The HEMR was reviewed and all patients with an appropriate International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) code indicating an ingested or aspirated FB were identified and retrieved for review. RESULTS. A total of 105 cases of FB ingestion or aspiration in children <12 years of age from January 2012 to December 2014 were identified from the HEMR. The patients' ages ranged from 4 months to 10 years (mean 3 years and 6 months), and 59.0% (n=62) were male and 41.0% (n=43) female. A total of 107 FBs were removed (two patients each had two coins removed). The commonest FBs were coins (n=77, 71.9%), followed by batteries (n=6, 5.6%), plastic toys (n=5, 4.7%), buttons (n=5, 4.7%), screws/washers (n=3, 2.8%), seeds (n=2, 1.9%), needles (n=2, 1.9%), bones (n=2, 1.9%), a marble (n=1, 0.9%), a rubber eraser (n=1, 0.9%), a curtain hook (n=1, 0.9%), a nail (n=1, 0.9%) and a wood speck (n=1, 0.9%). Of the FBs, 67 (62.6%) were in the oesophagus, 17 (15.9%) in the respiratory system, 14 (13%) in the intestine and 9 (8.4%) in the oral cavity. The average time from ingestion/aspiration to presentation was <48 hours. Of the FBs, 67 (62.6%) were removed via rigid oesophagoscopy and 13 (12.1%) via rigid bronchoscopy, 13 (12.1%) were passed rectally, and 9 (8.4%) were removed via grasping forceps in the oral cavity, 4 (3.7%) via thoracotomy and 1 (0.9%) via emergency laparotomy. A total of 15 complications included mucosal ulceration/slough (n=6, 40.0%), oesophageal perforation (n=3, 20.0%), aspiration pneumonia (n=3, 20.0%), and tracheal perforation, lung collapse and contact bleed (n=1 each, 6.7%). No patient presented in respiratory distress or needed emergency airway management, and there were no deaths. CONCLUSIONS. The development of a dedicated paediatric surgery service and the implementation of management protocols have resulted in excellent outcomes for this problem. <![CDATA[<b>Surgical skills deficiencies and needs of rural general practitioners in South Africa</b>]]> BACKGROUND. At present, much of the global surgical workforce consists of non-specialist physicians (general practitioners (GPs)) whose only formal surgical training was in medical school as an undergraduate. However, there is widespread concern that GPs do not have the skills necessary to deliver essential surgical care in a rural setting. This requires that a specific training programme be developed to train rural GPs in essential surgical skills for rural settings. OBJECTIVES. To perform a critical analysis to determine essential surgical skills required by GPs in rural South Africa, with the intention of developing the content of an accredited continuing professional development (CPD) learning programme to address needs identified. METHODS. This was a descriptive study in which a desk-top review analysis and a questionnaire survey were used to obtain both qualitative and quantitative data on essential skills required for rural surgical practice. RESULTS. Of 300 GPs, 102 (34.0%) completed the questionnaire. Some of the skills listed as essential for rural surgical practice were removal of foreign objects not in the visual axis (90.0%), packing of epistaxis (93.0%), haematoma drainage (78.3%) and wound debridement and suturing (96.0%). The study also identified the outcomes and essential content of a proposed CPD programme to provide GPs in the rural setting with the required surgical skills. CONCLUSIONS. Enhancing skills of GPs in essential surgical techniques and procedures through an accredited CPD short learning programme will ensure that adequate and comprehensive essential surgical care is provided to people living in rural communities. <![CDATA[<b>An assessment of the isoniazid preventive therapy programme for children in a busy primary healthcare clinic in Nelson Mandela Bay Health District, Eastern Cape Province, South Africa</b>]]> BACKGROUND. Tuberculosis (TB) is a significant contributor to the international and national burden of disease. Global estimates suggest that there were 10.4 million new cases of TB in 2015. Children accounted for ~10% of these cases, although in South Africa (SA) this figure is thought to be higher. Despite clear evidence that isoniazid preventive therapy (IPT) can reduce the risk of progression from TB infection to disease in TB contacts, IPT has been poorly implemented in SA national TB control programmes. OBJECTIVES. To determine current practices regarding the identification and management of child contacts (<5 years of age) at a primary care clinic in the Nelson Mandela Bay Health District, Eastern Cape Province, SA. METHODS. A cross-sectional descriptive study was conducted using a retrospective record review of infectious TB index patients aged &gt;15 years. Folders of index patients with bacteriologically confirmed pulmonary TB, who started TB treatment between 21 October 2011 and 28 February 2014, were included. A sample size of 246 child contacts was required to obtain adequate power. A 95% confidence interval (CI) was used to determine statistically significant results. RESULTS. Index patient records (N=491) were assessed and 261 child contacts identified. In a high percentage of index patient folders (87.5%; n=430), contacts were documented, although only 0.53 child contacts were identified per index patient. Of the 261 child contacts identified, 184 (70.5%) were screened for TB, 2 started TB treatment and 108/184 (58.7%) started IPT. For the remaining 74 (40.2%) children, there was no documentation of further management. Only 4 (3.7%) children completed the 24-week IPT course. Male patients reported fewer child contacts (χ² =7.31; p=0.01; odds ratio (OR) 0.6; 95% CI 0.42 - 0.86) and were less likely to bring contacts for screening (χ²=8.98; p=0.003; OR 0.41; 95% CI 0.24 - 0.72). Retreatment index patients were also less likely to bring contacts for screening (χ²=6.37; p=0.01; OR 0.45; 95% CI 0.25 -0.81) and those who were screened were less likely to initiate IPT (χ²=4.05; p=0.04; OR 0.54; 95% CI 0.3 - 0.95). CONCLUSION. Despite contacts being well documented, child contacts were poorly identified. The fall-out of children at each step from identification to IPT completion was unacceptably high. Contacts of male patients and retreatment index patients were at greater risk of poor management. Recommendations to improve IPT delivery at national and local level include a review of the national IPT guidelines, considering the relative success of shorter courses of TB prophylaxis, the use of standardised IPT stationery, staff training and the involvement of community health workers in contact management. <![CDATA[<b>The effect of different forms of heparin on point-of-care blood gas analysis</b>]]> BACKGROUND. Point-of-care blood gas analysis plays an integral role in the management of critically ill and injured patients presenting to the emergency department (ED). While the use of specially manufactured syringes containing electrolyte-balanced dried heparin is recommended when processing these specimens, alternatives including manually self-prepared syringes washed with liquid heparin or heparin vacutainers are still often used. OBJECTIVES. To assess the effect of two concentrations of liquid heparin and the use of heparin vacutainers on the reliability of blood gas analysis results compared with the recommended standard of dried heparin syringes in the ED setting. METHODS. Blood samples were drawn from 54 patients attending a tertiary-level hospital ED. Individual samples were distributed equally among each of four different collection devices: a dried heparin syringe, self-prepared syringes washed separately with 1 000 IU/mL and 5 000 IU/mL liquid heparin, and a heparin vacutainer. Results obtained from the standard dried heparin syringes were compared with those from the other three methods. RESULTS. For both the liquid heparin cohorts, partial pressure of carbon dioxide (pCO2), potassium (K+), sodium (Na+), ionised calcium (iCa²+) and haemoglobin had >20% of results falling beyond the total allowable error. iCa2+ and K+ results were most affected in the 5 000 IU/mL cohort and iCa2+ and Na+ in the 1 000 IU/ml cohort. pCO2, pH and iCa2+ were the most significantly affected in the heparin vacutainer cohort. CONCLUSIONS. Use of liquid heparin can result in significant negative bias in the majority of blood gas analytes, especially electrolytes. Heparin vacutainer use can result in unacceptable variations in the respiratory analytes. While standard dried heparin syringes may not always be available, it is of vital importance that practitioners be aware of these biases and limitations when using substitutes. <![CDATA[<b>High positive computed tomography yields in the emergency department might not be a positive finding</b>]]> BACKGROUND. There is growing pressure to reduce unnecessary computed tomography (CT) imaging requests that the radiology department receives from the emergency department (ED); however, information on acceptable usage rates and diagnostic yields remains scanty. OBJECTIVES. To describe the indications, clinical categories and positive yield rates of patients receiving CT scans in the ED. METHODS. A retrospective record review was done of all patients who received CT scans at an urban, adult academic ED during a 4-month period. Primary outcomes were to establish CT scan usage and positive yield rates. Other outcomes included analysis of indications, demographics and anatomical areas scanned. RESULTS. Scans (n=1 010) were analysed. The median age of patients was 36 (range 4 - 93) years. Male patients received 64.3% of all scans, as well as 75.7% of the scans performed for trauma. The majority of the scans were for trauma patients. However, non-trauma patients had a higher positive yield; the non-trauma positive yield rate was 61.8% compared with the trauma positive yield rate of 47.1% (p<0.001). The majority of scans performed were of the head (58%) and neck (20%), with lowest positive yield rates of 48.9% and 17%, respectively. The overall CT scan usage rate was 4.6% and overall positive rate 53.8%. CONCLUSION. A negative CT scan does not necessarily mean that the test was not indicated. Higher positive yield rates may reflect insufficient use of CT scanning by the ED. Local guidelines should be established to ensure judicious and effective clinical use of CT scans. <![CDATA[<b>Estimating the burden of cervical disease among HIV-infected women accessing screening services in South Africa: A model-based analysis</b>]]> BACKGROUND. Cervical cancer remains the second most common cancer among women worldwide, with much of the global burden occurring in low- and middle-income countries. HIV-infected women are at increased risk of human papillomavirus infection, preinvasive cervical disease and invasive cervical cancer (ICC). Funded through the United States President's Emergency Plan for AIDS Relief (PEPFAR) and working in collaboration with the South African (SA) Department of Health, our team supports cervical screening integrated within public sector HIV clinics in SA. OBJECTIVES. To estimate the burden of cervical disease among HIV-infected women accessing screening services supported through our programme. METHODS. We constructed conditional probability models to estimate the burden of grade 1 and grades 2/3 cervical intraepithelial lesions (CIN1 and CIN2/3) and ICC among two cohorts: one consisting of 3 190 HIV-infected women for whom only cytology results were available for analysis, and another consisting of 75 358 HIV-infected women for whom neither cytology nor histology results were available. Parameter estimates for the models were derived from routinely collected programmatic data and published clinical trials. RESULTS. Between January 2009 and November 2015, 75 358 HIV-infected women underwent Pap smear screening in public sector clinics supported by our cervical cancer prevention programme. Based on modelling analysis, we estimate that 46 123 cases of CIN1 (range 45 500 -49 608), 13 598 cases of CIN2/3 (range 12 749 - 14 828), and 104 cases of ICC (range 61 - 186) occurred in this population. CONCLUSIONS. Our findings highlight the magnitude of cervical disease among HIV-infected women in SA. <![CDATA[<b>Restaurant smoking sections in South Africa and the perceived impact of the proposed smoke-free laws: Evidence from a nationally representative survey</b>]]> BACKGROUND. The South African Minister of Health announced in 2016 that he intends to introduce tobacco control legislation that will prohibit smoking in restaurants. This will substantially strengthen the Tobacco Products Control Act (1993, as amended), which currently allows restaurants to have a dedicated, enclosed indoor smoking area. OBJECTIVES. To analyse current smoking policies of restaurants, whether and how these policies have changed over the past decade, and restaurateurs' attitudes to the proposed legislative changes. Methods. From a population of nearly 12 000 restaurants, derived from four websites, we sampled 2 000 restaurants, stratifying by province and type (independent v. chain) and disproportionately sampling small strata to ensure meaningful analysis. We successfully surveyed 741 restaurants, mostly by phone. We also surveyed 60 franchisors from a population of 82 franchisors. RESULTS. Of the restaurants sampled, 44% were 100% smoke-free, 44% had smoking sections outside, 11% had smoking sections inside, and 1% allowed smoking anywhere. Smoking areas were more common in independent restaurants (62%) than franchised restaurants (43%). Of the restaurants with a smoking section, 33% reported that the smoking sections were busier than the non-smoking sections. Twenty-three percent of restaurants had made changes to their smoking policies in the past 10 years, mostly removing or reducing the size of the smoking sections. Customer requests (39%), compliance with the law (35%) and cost and revenue pressures (14%) were the main reasons for changing smoking policies. Of the restaurant respondents 91% supported the current legislation, while 63% supported the proposed legislative changes; 68% of respondents who were aware of the proposed legislation supported it, compared with 58% of respondents who were not aware of the proposed legislation. CONCLUSIONS. In contrast to the vehement opposition to the 1999 legislation, which resulted in restaurants going partially smoke-free in 2001, there was limited opposition from restaurants to the proposed legislative changes that would make restaurants 100% smoke-free. Support for the proposed legislation will probably increase as the restaurant industry and the public are made more aware of the proposed legislative changes, although public opinion is vulnerable to tobacco industry-led campaigns.