FCTC 2030 - a programme to accelerate the implementation of WHO Framework Convention for Tobacco Control in low- and middle-income countries: A mixed-methods evaluation

Advancing progress on tobacco control in low-income and middle-income countries through economic analysis

BACKGROUND

More than 80% of the world's 1.3 billion tobacco users live in low-income and middle-income countries (LMICs), where progress to address tobacco and its harms has been slow. The perception that tobacco control detracts from economic priorities has impeded progress. The Secretariat of the WHO Framework Convention on Tobacco Control (FCTC) is leading the FCTC 2030 project, which includes technical assistance to LMICs to analyse the economic costs of tobacco use and the benefits of tobacco control.

METHODS

The Secretariat of the WHO FCTC, United Nations Development Programme and WHO supported 21 LMICs between 2017 and 2022 to complete national investment cases to guide country implementation of the WHO FCTC, with analytical support provided by RTI International. These country-level cases combine customised estimates of tobacco's economic impact with qualitative analysis of socio-political factors influencing tobacco control. This paper overviews the approach, observed tobacco control advancements and learnings from 21 countries: Armenia, Cabo Verde, Cambodia, Chad, Colombia, Costa Rica, El Salvador, Eswatini, Georgia, Ghana, Jordan, Laos, Madagascar, Myanmar, Nepal, Samoa, Sierra Leone, Sri Lanka, Suriname, Tunisia and Zambia.

RESULTS

Tobacco control advancements in line with investment case findings and recommendations have been observed in 17 of the 21 countries, and many have improved collaboration and policy coherence between health and economic stakeholders.

CONCLUSIONS

Tobacco control must be seen as more than a health concern. Tobacco control leads to economic benefits and contributes to sustainable development. National investment cases can support country ownership and leadership to advance tobacco control.

Examining local smoke-free coalitions in Armenia and Georgia: context and outcomes of a matched-pairs community-randomised controlled trial

INTRODUCTION

Local coalitions can advance public health initiatives such as smoke-free air but have not been widely used or well-studied in low-income and middle-income countries.

METHODS

We conducted a matched-pairs community-randomised controlled trial in 28 communities in Armenia and Georgia (N=14/country) in which we helped establish local coalitions in 2019 and provided training and technical assistance for coalition activity promoting smoke-free policy development and enforcement (2019-2021). Surveys of ~1450 households (Fall 2018, May-June 2022) were conducted to evaluate coalition impact on smoke-free policy support, smoke-free home adoption, secondhand smoke exposure (SHSe), and coalition awareness and activity exposure, using multivariable mixed modelling.

RESULTS

Bivariate analyses indicated that, at follow-up versus baseline, both conditions reported greater smoke-free home rates (53.6% vs 38.5%) and fewer days of SHSe on average (~11 vs ~12 days), and that intervention versus control condition communities reported greater coalition awareness (24.3% vs 12.2%) and activity exposure (71.2% vs 64.5%). Multivariable modelling indicated that intervention (vs control) communities reported greater rates of complete smoke-free homes (adjusted Odds Ratio [aOR] 1.55, 95% confiedence interval [CI] 1.11 to 2.18, p=0.011) and coalition awareness (aOR 2.89, 95% CI 1.44 to 8.05, p=0.043) at follow-up. However, there were no intervention effects on policy support, SHSe or community-based activity exposure.

CONCLUSIONS

Findings must be considered alongside several sociopolitical factors during the study, including national smoke-free policies implementation (Georgia, 2018; Armenia, 2022), these countries' participation in an international tobacco legislation initiative, the COVID-19 pandemic and regional/local war). The intervention effect on smoke-free homes is critical, as smoke-free policy implementation provides opportunities to accelerate smoke-free home adoption via local coalitions.

TRIAL REGISTRATION NUMBER

NCT03447912.

Controlling smoking: A smoking epidemic model with different smoking degrees in deterministic and stochastic environments

Engaging in smoking not only leads to substantial health risks but also imposes considerable financial burdens. To deepen our understanding of the mechanisms behind smoking transmission and to address the tobacco epidemic, we examined a five-dimensional smoking epidemic model that accounts for different degrees of smoking under both deterministic and stochastic conditions. In the deterministic case, we determine the basic reproduction number, analyze the stability of equilibria with and without smoking, and investigate the existence of saddle-node bifurcation. Our analysis reveals that the basic reproduction number cannot completely determine the existence of smoking, and the model possesses bistability, indicating its dynamic is susceptible to interference from environmental noises. In the stochastic case, we establish sufficient conditions for the ergodic stationary distribution and the elimination of smokers by constructing appropriate Lyapunov functions. Numerical simulations suggest that the effects of inevitable random fluctuations in the natural environment on controlling the smoking epidemic may be beneficial, harmful, or negligible, which are closely related to the noise intensities, initial smoking population sizes, and the effective exposure rate of smoking transmission (β). Given the uncontrollable nature of environmental random effects, effective smoking control strategies can be achieved by: (1) accurate monitoring of initial smoking population sizes, and (2) implementing effective measures to reduce β. Therefore, it is both effective and feasible to implement a complete set of strong MPOWER measures to control smoking prevalence.

Associations Between Pro/Anti-Tobacco Media and Messaging Exposure and Knowledge and Support of Smoke-Free Policy Among Adults in Armenia and Georgia

CONTEXT

Despite high smoking rates, Armenia and Georgia recently adopted smoke-free policies (2022 and 2018).

OBJECTIVE

We examined associations between exposure to pro-tobacco media (news opposing smoke-free policies; cigarette, e-cigarette, heated tobacco product [HTP] advertisements) and anti-tobacco media (media, community-based action) and (1) knowledge that the policies applied to alternative tobacco products (ATPs), and (2) support for the policies applying to ATPs and various settings.

DESIGN

We analyzed 2022 survey data.

SETTING

Data were from 28 communities in Armenia and Georgia.

PARTICIPANTS

The sample comprised 1468 adults (31.6% past-month smokers).

METHODS

We conducted multivariable regressions, controlling for country and sociodemographics.

RESULTS

Participants were knowledgeable that the policy applied to ATPs (79.2%) and supportive of them applying to ATPs and various settings (means = 3.43 and 3.00; 1-4 = strongly support). Greater exposure to anti-tobacco media/community-based action correlated with more likely knowing that the policies applied to ATPs and greater support of the policies applying to various settings; HTP advertisement exposure correlated with less support of the policies applying to various settings. Less exposure to news opposing smoke-free policies and greater exposure to media supporting such policies correlated with greater support of the policies applying to ATPs.

CONCLUSIONS

Media and community-based action may promote smoke-free policy knowledge and support. HTP advertisements may uniquely undermine smoke-free policies.