Second Hand Smoke Exposure among Children in Indian Homes: Findings from the Global Adult Tobacco Survey

Children are vulnerable to second hand smoke (SHS) exposure because of limited control over their indoor environment, especially at homes. This study determines the magnitude, patterns and determinants of SHS exposure in the home among children in India. Data collected under the Global Adult Tobacco Survey (GATS) data, a household survey of adults ≥15 years of age during 2016-2017 conducted in India were analyzed to estimate the proportion of children exposed to SHS in their homes. GATS estimates and national census population projections for 2020 were also used to estimate the number of children exposed to SHS in the homes. Nearly half (46.5%) of the children <15 years of age were exposed to SHS in their homes in India which extrapolates to nearly an estimated 170 million. Children living in rural households, north-east and central regions and households with an adult smoker were more likely to be exposed to SHS. SHS exposure among children in home is high in India which calls for adoption of voluntary smoke-free homes initiative and promoting cessation among smokers.

Factors Influencing Tobacco Cessation in India: Findings from the Global Adult Tobacco Survey-2

OBJECTIVE

The study aimed to assess the socio-demographic and other correlates of cessation behavior across tobacco products among the adult population in India.

METHODS

We used data of adults (aged ≥15 years) who were current or former tobacco users (smoking and/or smokeless tobacco) from the Global Adult Tobacco Survey (GATS) India, conducted during 2016-17. The detailed analysis was done for current daily smokers (N=7,647), former daily smokers (N=1,353), and current daily smokeless tobacco users (N=1,2721). Multivariate logistic regression was separately performed to find the associated factors with attempts to quit, successful quitting, different cessation methods of smoking, and smokeless tobacco use.

RESULTS

The findings of the study indicated that daily smokers, higher educated, urban residents and employed were more likely to quit smoking compared to their counterparts. Successful quitting of smoking was higher for employed, higher educated, current users of smokeless tobacco and older adults.  For smokeless tobacco users, non-daily users, highly educated, urban residents, and employed were more likely to attempt to quit compared to their counterparts. Successful quitting of smokeless tobacco was higher for unemployed, highly educated, urban residents and current non-smokers, and higher age group adults.

CONCLUSION

The findings of this study suggest a need for professionally channelized cessation interventions to reduce the prevalence and relapse of tobacco use and increase the quit rate. Well-designed, large-scale research into specific tobacco cessation methods is needed to establish the association between different tobacco cessation methods and increased quit rates.

Hardening determinants among adult daily smokers in nine African countries: Data from the Global Adult Tobacco Survey

Little has been reported about hardening nor softening indicators in Africa where smoking prevalence is low. We aimed to examine the determinants of hardening in nine African countries. We conducted two separate analyses using data from the most recent Global Adult Tobacco Survey in Botswana, Cameroon, Egypt, Ethiopia, Kenya, Nigeria, Senegal, Tanzania, and Uganda (total sample of 72,813 respondents): 1) multilevel logistic regression analysis to assess individual and country-level factors associated with hardcore, high dependence, and light smoking.; 2) a Spearman-rank correlation analysis to describe the association between daily smoking and hardcore, high dependence, and light smoking at an ecological level. Age-standardized daily smoking prevalence varied from 37.3% (95 %CI: 34.4, 40.3) (Egypt) to 6.1% (95 %CI: 3.5, 6.3) (Nigeria) among men; and 2.3% (95 %CI: 0.7, 3.9) (Botswana) to 0.3% (95 %CI: 0.2, 0.7) (Senegal) among women. The proportion of hardcore and high-dependence smokers was higher among men whereas for light smokers the proportion was higher among women. At the individual level, higher age and lower education groups had higher odds of being hardcore smokers and having high dependence. Smoke-free home policies showed decreased odds of both being hardcore and highly dependent smokers daily smoking correlated weakly and negatively with hardcore smoking (r = -0.243, 95 %CI: -0.781, 0.502) among men and negatively with high dependence (r = -0.546, 95 %CI: -0.888, 0.185) and positively with light smokers (r = 0.252, 95 %CI: -0.495, 0.785) among women. Hardening determinants varied between the countries in the African region. Wide sex differentials and social inequalities in heavy smoking do exist and should be tackled.

Awareness of electronic cigarettes in India: Findings from the 2016-2017 Global Adult Tobacco Survey (GATS)

INTRODUCTION

Electronic nicotine delivery systems (ENDS) have recently emerged as a public health threat globally. Despite the low proportion of e-cigarette users (1.22%) reported in the Global Adult Tobacco Survey-2, the Government of India enacted the Prohibition of E-cigarettes Act 2019 (PECA), prohibiting all forms of ENDS/ENNDS. The current analysis presents nationally representative findings on the level of awareness of e-cigarettes in India and its correlates and characteristics of those aware of e-cigarettes.

METHODS

The current secondary analysis from GATS-2 among adults aged ≥15 years from all states and Union Territories of India used a standard protocol for data collection and management. A multi-stage cluster sampling design was used. The respondents who were aware of e-cigarettes were included (n=2524). Binomial logistic regression analysis was conducted, and adjusted odds ratios (AORs) with 95% CI, were calculated to measure the associations between independent and dependent variables.

RESULTS

Only 3.4% of the respondents were aware (either heard or seen) of e-cigarettes and their awareness was found significantly higher among males (AOR=2.07; 95% CI: 1.90-2.24), urban population (AOR=2.83; 95% CI: 2.61-3.07), and higher education (AOR=0.41; 95% CI: 0.38-0.45).

CONCLUSIONS

Public awareness campaigns about the harms of e-cigarettes and the law (PECA) need to be rolled out in urban and rural areas. Capacity-building exercises of implementers and enforcers at the grassroots level could also support communicating the harms to hard-to-reach groups. Further, regular compliance monitoring of the legislation and prosecution of violators would facilitate its effective implementation at the national and sub-national levels.

Socioeconomic inequalities in tobacco cessation among Indians above 15 years of age from 2009 to 2017: evidence from the Global Adult Tobacco Survey (GATS)

BACKGROUND

Tobacco is strongly associated with socioeconomic status (SES), however evidence on differences in tobacco cessation by socio-economic attributes remains fragmented, especially in developing countries. The present study aims to estimate socioeconomic inequalities in tobacco cessation among Indian men and women above 15 years of age.

METHODS

Two rounds of the Global Adult Tobacco Survey (2009-2010 and 2016-2017), India was used to estimate the association between socioeconomic indicators (wealth index and educational attainment) with tobacco cessation using a multinomial modeling approach.

RESULTS

After adjusting for SES and demographic variables, we found significantly lower odds in tobacco cessation rates among respondents of GATS-2 (2016-2017) compared to GATS-1 (2009-2010). Additionally, huge regional variations in smoking and smokeless tobacco cessation rates were observed. Population belonging to the low wealth-asset score had higher odds of cessation compared to the high asset index. While greater educational attainment was seen to have a positive effect on cessation, the results were insignificant. Individuals belonging to the northeastern geographic region were seen to have the lowest odds of cessation. Though awareness about the health hazards of tobacco increased, cessation declined for both men and women. Quitting smokeless tobacco among men and women was observed to be lower than smoking.

CONCLUSION

This study is the first to provide national-level evidence on the association between tobacco cessation and socioeconomic attributes among Indians above 15 years of age. Findings suggest the need to scale up tobacco cessation services separately for men and women, and also for smoking and smokeless tobacco forms.

The association between the retail price of manufactured cigarettes and bidis on current smoking status in India

INTRODUCTION

In India, the retail prices of bidis and cigarettes varied between the two Global Adult Tobacco Surveys (GATS) conducted in 2009-2010 and 2016-2017. The relationship between the retail price of smoked tobacco products and their use is unclear for India. Our study thus aimed to use available datasets to investigate the association between the retail price and current smoking status of bidis and cigarettes in India.

METHODS

Current smoking status data for bidis and cigarettes were obtained from the two GATS rounds. The average state-level retail prices of bidis and cigarettes were obtained from India's Consumer Price Index- Industrial Workers database. Descriptive statistics were used to describe current smoking status patterns. Generalized Linear Mixed Models were used to investigate the association between the retail prices and current smoking status of bidis and cigarettes.

RESULTS

For cigarettes, an increase in the average retail price by one Indian Rupee was associated with a reduction in the odds of being a current smoker of 7% (OR=0.925; 95% CI: 0.918-0.932, p<0.001). For bidis, the association between the retail price and current smoking status was not statistically significant (OR=1.01; 95% CI: 1.00-1.02, p=0.082).

CONCLUSIONS

Current increases in the retail prices of tobacco products in India seem to have an impact on the use of cigarettes but not bidis. This highlights the need for tobacco product tax increases that result in sufficient retail prices increase to make all tobacco products less affordable and reduce their use.

Tobacco use prevalence and its determinate factor in Ethiopia- finding of the 2016 Ethiopian GATS

BACKGROUND

Tobacco, one of the risk factors for non-communicable diseases, kills 8 million people each year. Like other sub-Saharan countries, Ethiopia faces the potential challenge of a tobacco epidemic. However, there is no organized data on the prevalence of tobacco use in the country. Therefore, this study aims to determine adult tobacco use in Ethiopia.

METHODS

The study was conducted using the WHO and CDC GATS survey methods. Complex survey analysis was used to obtain prevalence and population estimates with 95% confidence intervals. Bivariate regression analyses were employed to examine factors related to tobacco use.

RESULTS

The overall tobacco use percentage was 5.0% [95% CI (3.5, 6.9)], of which 65.8% [95% CI (53.4, 76.3)] only smoked tobacco products; 22.5% [95% CI (15.7, 31.2)] used smokeless tobacco only; and 11.8% [95% CI (6.5, 20.4)] used both smoked and smokeless tobacco products. In 2016, more men adults (8.1%) used tobacco than women did (1.8%). Eight out of eleven states have a higher smoking rate than the national average (3.7%). Gender, employment, age, religion, and marital status are closely linked to current tobacco use (p-value< 0.05). Men adults who are employed, married, and mostly from Muslim society are more likely to use tobacco.

CONCLUSION

The prevalence of tobacco use is still low in Ethiopia. However, the percentage of female smokers is increasing, and regional governments such as Afar and Gambella have a relatively high prevalence. This calls for the full implementation of tobacco control laws following the WHO MPOWER packages. A tailored tobacco control intervention targeting women, younger age groups, and regions with a high proportion of tobacco use are recommended.

Declining trends in smokeless tobacco use among Indian women: findings from global adult tobacco survey I and II

BACKGROUND

Smokeless Tobacco (SLT) use is culturally rooted and more acceptable among women in India. SLT is a significant risk for oral cancers and has other adverse health outcomes on women's general as well as reproductive health. This study aimed to estimate and compare the prevalence and correlates of SLT among adult females in India using Global Adult Tobacco Survey (GATS), 2009-2010 (GATS 1) and 2016-2017 (GATS 2).

METHODS

Data from a nationally representative cross-sectional study GATS 1 (n = 35,529) and GATS 2 (n = 40,265) were analysed for adult female smokeless tobacco users. Correlates of SLT exposure were assessed separately using binary logistic regression. Multivariable logistic regression analysis was done for the variables which computed p < 0.1. The association was expressed as Adjusted Odds ratio with 95% confidence intervals.

RESULTS

There was a reduction in prevalence of SLT use among women in India between GATS 1 (18.4%) and GATS 2 (12.8%). SLT use was highest among the North-Eastern women in both rounds [AOR: 4.567 (3.942-5.292) during GATS-1 and 9.149 (7.722-10.839) during GATS-2]. Odisha had highest prevalence of 56.53% while Himachal Pradesh had lowest 0.14% during the recent GATS 2 survey. 33.3% vs. 34.80% of the participants were willing to quit tobacco in Central region across both rounds of survey.

CONCLUSIONS

Although, smokeless tobacco prevalence among females has reduced between 2009 and 2016 in India, yet tobacco control strategies need further pace. Hence, more focused gender-based tobacco control programs and policies are the need of time.

Raising the Age of Purchase and Use of Tobacco Product in Bangladesh: Benefits and Challenges in Protecting Youth from the Tobacco Epidemic

BACKGROUND

Tobacco use among young and adolescents is the biggest threat to public health globally. In Bangladesh, every one in 14 youth (13-15 years) uses tobacco in some form. While this problem is growing in the country, we estimate the underage initiation of tobacco use and present evidence that policy measures like increasing the age of purchase and use from the current 18 years to 21 years in the country backed with current tobacco control efforts and adopting vendor licensing will significantly reduce future tobacco burden.

METHOD

We analysed the two rounds of nationally representative Global Adult Tobacco Survey (GATS) data: GATS-1 (2009-10) and GATS-2 (2016-17) and segregated the data for two categories of tobacco consumption (smokers and smokeless tobacco users) based on the age of initiation (<18, 18-21 and >21 years). Consumption patterns were also analyaed by using the GATS-2 data. Projections from sub-national level analysis for youth initiating tobacco use before 21 years and change in the prevalence of overall underage tobacco users were calculated based on weighted value.

RESULT

According to GATS-2, around 89% of current tobacco users initiated tobacco use into daily use before the age of 18 years in Bangladesh. Whereas, striking differences were observed (statistically significant) for the average age of initiation of smoking among smokers aged 20-34 increased from 17.4 in 2009 to 19.3 years; and 20.1 to 22 years for SLT.  Moreover, more than 24% of them initiated into regular smoking before the age of 15 years.

CONCLUSION

There is an increasing trends of tobacco initiation among the underage youth of Bangladesh. By increasing the age of access, sale, purchase, and use of tobacco from current 18 years to 21 years will significantly reduce youth initiation and taper down the overall adult tobacco use prevalence over the long run in Bangladesh.

Tobacco consumption trends and correlates of successful cessation in Indian females: Findings of Global Adult Tobacco Surveys

BACKGROUND

Female gender is being affected disproportionately by tobacco use. The correlates of tobacco use among women are different from men, which has not been studied in India. To develop gender-sensitive interventions and policies in tobacco control, it's essential to ascertain the factors that affect tobacco consumption and successful cessation among Indian women.

METHODS

This secondary data analysis was done for females respondents aged >15 years using the data generated from the GATS-1 (2009-2010) and GATS-II (2016-2017). The primary dependent variables included interest in quitting smoking/SLT, attempt to quit smoking/SLT, successful quitting. The independent variables were broadly categorized as a community, household, and individual level. Simple descriptive analysis using % age relative change was used to calculate the change in tobacco consumption between two rounds of GATS, whereas; bivariate and multivariable logistic regression were used to calculate the unadjusted and adjusted odds ratio for cessation related variables (GATS-2).

RESULTS

There was a 29.5% relative reduction in the prevalence of tobacco use in round-2 among females. A maximum reduction in the prevalence was observed in the 15-29 years (-51.3%), those not exposed the media advertisements (-19.9%). While unadjusted OR depicted that unmarried women, young age, asked by health workers about tobacco use, and advice given by them increased the interest in quitting smoking, none of them emerged to be significant on a multivariable logistic regression except the advice given by the health care provider. Successful cessation (>6 months) of SLT products is possible in urban areas, with decreased exposure to media advertisements.

CONCLUSION

There is an urgent need for gender-sensitive policies in tobacco control and the integration of these policies with relevant national health programs. This shall help to synergize efforts and obtain better outcomes that would support the overarching goal of tobacco-free India.

Social determinants of dual tobacco use in India: An analysis based on the two rounds of global adult tobacco survey

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First study from India and south Asia examining trends and socioeconomic predictor of dual tobacco use.

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Considerable disparity in dual tobacco use across socioeconomic groups evident.

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Time adjusted result show various factors that determined dual tobacco use.

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There is a need for targeted cessation interventions among dual tobacco users as no proven pharmocological or behavioural cessation model exists for them.

This study examines the socioeconomic determinants of dual use of smoked and smokeless tobacco (SLT) in India between 2009–10 and 2016–17. Data from two rounds of the nationally representative cross-sectional Global Adult Tobacco Survey (GATS) conducted in 2009–10 and 2016–17 was used. Complete sample size from both rounds of survey covering 143,333 individuals (GATS I: 69,296 and GATS II: 74,037) from 153,239 households (GATS I: 76,069 and GATS II: 77,170) included in the study. Dual use was assessed based on current smoked and SLT users in both rounds. Bivariate analysis was applied to assess differences in dual tobacco use by socioeconomic status (SES) and across regions, whereas, pooled sampled analysis was conducted to examine the determinants of dual use applying multinomial logistic regression model. Findings reveal that dual use has declined in India from nearly 5% in 2009–10 to 3.4% in 2016–17. Considerable regional and SES differences in dual use are evident. Multivariate results indicate, while age is positively associated with dual use, education and household wealth was negatively associated. Dual use of tobacco was found to be considerably higher among men as compared to women (RRR: 15.66, 95%CI 14.20–17.27). Awareness about the adverse health consequences of tobacco was also negatively associated with dual tobacco use (RRR: 0.56, 95%CI 0.50–0.64). Future awareness and enforcement efforts should focus on all forms of tobacco, especially targeting vulnerable SE groups.

The effect of price and tax policies on the decision to smoke among men in Kenya

AIMS

To assess the impact of cigarette prices on male smoking initiation and cessation in Kenya from 1960 to 2014.

DESIGN

Longitudinal study using individual level data from the 2014 Global Adult Tobacco Survey (GATS) and historical data on cigarette prices.

SETTING

Kenya.

PARTICIPANTS

A total of 2079 men, among whom 619 identified as ever-smokers.

MEASUREMENTS

Self-reported data on the years of smoking initiation and cessation, merged with historical data on cigarette prices. We employed several methodologies to estimate the effect of prices on smoking transitions, including a pooled linear model with propensity score matching (PSM).

RESULTS

Price increases were negatively associated with smoking initiation, with price elasticity of initiation ranging from -0.03 (-0.066 to -0.000) to -0.14 (-0.216 to -0.0563). The association was two to three times larger for younger male adults compared with the average. Price increases were correlated with increased cessation for younger males, with a price elasticity of 0.08 (0.027-0.141) and for low-income males with a price elasticity of 0.16 (-0.752 to 0.429).

CONCLUSIONS

Cigarette price increases in Kenya between 1960 and 2014 were negatively associated with males' smoking initiation and positively associated with younger and lower-income males' cessation.

Perceptions about the harmfulness of tobacco among adults in Uganda: Findings from the 2013 Global Adult Tobacco Survey

INTRODUCTION

Preferential option for some tobacco products over others might be attributed to inherent misconceptions about the harmfulness of tobacco. We analysed data from Uganda’s Global Adult Tobacco Survey (GATS) to assess misconceptions about the harmfulness of tobacco and associated factors.

METHODS

Data were obtained from the 2013 Uganda Global Adult Tobacco Survey (GATS) of persons in Uganda of age ≥15 years among 8508 participants selected using a multi-stage sampling design to provide nationally representative estimates of the adult population. Participants were asked about perceptions of the harmfulness of smoking, using smokeless tobacco and whether all kinds of cigarettes are equally harmful. Weighted logistic regression analysis was used to find factors associated with the dependent variables.

RESULTS

Among daily smokeless tobacco users, 98 (62%) were unaware that smokeless tobacco causes serious illness. Compared with participants without formal education, participants with primary education were less likely to be unaware that smoking causes serious illness (AOR=0.64, 95% CI: 0.48–0.84) as were participants with secondary education (AOR=0.28, 95% CI: 0.19–0.42) and participants with University education or higher (AOR=0.26, 95% CI: 0.11–0.58). Compared with participants who did not use any smokeless tobacco products, participants who used smokeless tobacco products less than daily were more likely to be unaware that smokeless tobacco causes serious illness (AOR=1.39, 95% CI: 0.54–3.61) as were participants who used smokeless tobacco products daily (AOR=5.87, 95% CI: 3.67–9.40). Compared with participants who did not use any smoked tobacco products, participants who used smoked tobacco products less than daily were more likely to believe that all cigarettes are equally harmful (AOR=2.40, 95% CI: 1.32–4.37) as were participants who used smoked tobacco products daily (AOR=3.08, 95% CI: 2.37–4.00).

CONCLUSIONS

There is a high level of unawareness about the harmfulness of tobacco use particularly among tobacco users. The National Tobacco Control Program should prioritise public awareness and education about the dangers of tobacco use in the Tobacco Control Policy and National Tobacco Control Strategic Plan.

Correlates of attempting to quit smoking among adults in Bangladesh

Background

Quit attempts are very essential in population-based smoking cessation. Little is known about the correlates of making a quit attempt of smoking in Bangladesh. We aimed to examine correlates of making a quit attempt of smoking among adults in Bangladesh.

Methods

We used data from the 2009 Global Adult Tobacco Survey, Bangladesh. A total of 2217 adult current smokers (2141 males and 76 females) aged 15 years and older who participated in the survey were included. We compared socio-demographic, behavioral, motivational, knowledge and attitudes towards smoking, quitting methods utilized, use of social media to quit smoking, and environmental characteristics of current smokers who made an attempt to quit with those who made no quit attempt during the previous 12 months of the survey. We applied multivariable logistic regression models for analyzing the data.

Results

Among the 2217 current smokers, 1058 (47.72%) made attempt to quit. We found respondents who smoked their first cigarette within 6 to 30 min of waking up were more likely to make an attempt to quit than those who smoked their first cigarette within 5 min of waking. Moreover, among daily current smokers who smoked 10–19 manufactured cigarettes per day were less likely to make a quit attempt. We also found intention to quit smoking, smoking rules inside the home, and exposure to anti-smoking advertisements as significant correlates of making a quit attempt of smoking among adults in Bangladesh.

Conclusions

Policymakers should consider our findings when implementing tobacco control programs in Bangladesh.

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Quit attempts are very essential in population-based smoking cessation.

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Among the 2233 current smokers, 1058 individuals attempted to quit smoking.

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Smokers who don't smoke quickly after waking were more likely to make quit attempt.

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Smokers who lived in a smoke-free home were also more likely to make quit attempt.

Gender, age, social disadvantage and quitting smoking in Argentina and Uruguay

INTRODUCTION

Cessation of tobacco use has the potential to provide the greatest immediate benefits for tobacco control. Understanding the social determinants of smoking cessation is an essential requirement for increasing smoking cessation at the population level. The purpose of this study was to analyze the socio-economic dimensions associated with cessation success among adults in Argentina and Uruguay.

MATERIAL AND METHODS

Data from the Global Adult Tobacco Survey (GATS), a cross-sectional, population-based, nationally representative survey conducted in Argentina (n=5,383) and Uruguay (n=4,833) was utilized. Univariable and multivariable logistic regression analyses with results being presented as odds ratios (OR) with 95% confidence intervals were applied to study differences among those respondents who sustained smoking abstinence (≥1 year) and those who continued smoking.

RESULTS

The GATS study revealed that social gradients in tobacco quitting exist in Argentina and Uruguay. Being aged 25-34, particularly men in Uruguay, women in Argentina, low educated men in Argentina and having a lower asset index were associated with reduced odds for quitting.

CONCLUSIONS

Factors that are driving differences in smoking cessation between diverse social groups in Latin America countries need to be considered when implementing relevant interventions to ensure tobacco control strategies work effectively for all population segments.

Open access tools for quality-assured and efficient data entry in a large, state-wide tobacco survey in India

Background: A large state-wide tobacco survey was conducted using modified version of pretested, globally validated Global Adult Tobacco Survey (GATS) questionnaire in 2015–22016 in Tamil Nadu, India. Due to resource constrains, data collection was carrid out using paper-based questionnaires (unlike the GATS-India, 2009–2010, which used hand-held computer devices) while data entry was done using open access tools. The objective of this paper is to describe the process of data entry and assess its quality assurance and efficiency.

Methods: In EpiData language, a variable is referred to as ‘field’ and a questionnaire (set of fields) as ‘record’. EpiData software was used for double data entry with adequate checks followed by validation. Teamviewer was used for remote training and trouble shooting. The EpiData databases (one each for each district and each zone in Chennai city) were housed in shared Dropbox folders, which enabled secure sharing of files and automatic back-up. Each database for a district/zone had separate file for data entry of household level and individual level questionnaire.

Results: Of 32,945 households, there were 111,363 individuals aged ≥15 years. The average proportion of records with data entry errors for a district/zone in household level and individual level file was 4% and 24%, respectively. These are the errors that would have gone unnoticed if single entry was used. The median (inter-quartile range) time taken for double data entry for a single household level and individual level questionnaire was 30 (24, 40) s and 86 (64, 126) s, respectively.

Conclusion: Efficient and quality-assured near-real-time data entry in a large sub-national tobacco survey was performed using innovative, resource-efficient use of open access tools.

Correlates of unsuccessful smoking cessation among adults in Bangladesh

Having 21.9 million adult smokers, Bangladesh ranks among the top ten heaviest smoking countries in the world. Correlates of unsuccessful smoking cessation remain unknown. We aimed to identify the correlates of unsuccessful smoking cessation among adults in Bangladesh.

We used data from the 2009 Global Adult Tobacco Survey (GATS) for Bangladesh. We compared socio-demographic, belief about health effect of smoking, and environmental characteristics of current smokers who had a recent failed quit attempt during the past 12 months of the survey (unsuccessful quitters) with those former smokers who had quit ≥ 12 months earlier of the survey and had not relapsed (successful quitters). Data were analyzed using logistic regression model and generalized estimating equations.

A total of 1552 smokers (1058 unsuccessful quitters and 494 successful quitters) aged 15 years and older who participated in the survey was included in this study. Among the smokers, 1058 (68%) were unsuccessful quitters. Our analysis showed that older aged, female, and higher educated smokers were less likely to quit unsuccessfully. Moreover, who believed that smoking causes serious illness were also less likely to quit unsuccessfully. For the interaction between place of residence and smoking rules inside home, we found that among the smoker's, in those house smoking was allowed, and who lived in urban place were less likely to be unsuccessful in quitting than those who lived in rural place.

Our findings suggest a cessation program that requires integrated approach with a view to considering these findings in setting up.

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The interaction effects for smoking cessation has been rarely investigated.

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Almost 70% of adult smokers were unsuccessful quitters.

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Older aged, female, and educated smokers were less likely to quit unsuccessfully.

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Belief about harmful effect of smoking associated with unsuccessful smoking cessation

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Interaction between smoking rules inside home and place of residence was observed.

Prevalence of tobacco smoking in Vietnam: findings from the Global Adult Tobacco Survey 2015

OBJECTIVES

We report the prevalence of tobacco smoking among adult populations in Vietnam, 2015.

METHODS

The Vietnam GATS 2015 was a nationally representative survey. 9513 households were selected using two-stage random systematic sampling method. Handheld computers were used for capturing data. Data collection was carried-out by National Statistics Office of Vietnam in 2015. Weight was used in all estimates.

RESULTS

The Vietnam GATS 2015 found that the prevalence of smoking in Vietnam was 22.5% overall, 45.3% among men, and 1.1% among women. The overall 2015-2010 reduction in prevalence of any tobacco product was 5.3%. However, the reduction was not statistically significant. The significant reduction in prevalence of tobacco smoking was found for any type of cigarette (-8.4%), and especially for hand-rolled cigarettes (-38.3%). The use of cigarettes significantly decreased in urban areas (-14.7%).

CONCLUSION

The reduction in the prevalence of tobacco smoking in Vietnam during the last 5 years (2010-2015) has not been as high as expected, especially in rural areas. Further efforts are needed to continue to reduce the harms caused by tobacco smoking.

The Association between Warning Label Requirements and Cigarette Smoking Prevalence by Education-Findings from the Global Adult Tobacco Survey (GATS)

Introduction: The Guidelines for the implementation of Article 11 of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) require that cigarette health warning labels should include pictures and take up 50% or more of the principal display area. This study examined how the association between large pictorial warnings, those covering ≥50% of the front and back of the package, and the prevalence of cigarette smoking varies by educational attainment. Methods: We pooled individual-level tobacco use data from the Global Adult Tobacco Survey (GATS) in 18 countries between 2008 and 2013 and linked them with warning label requirements during the same period from the MPOWER database and reports regarding warnings. The respondents’ self-reported exposure to warnings was examined according to education. Logistic regressions were further employed to analyze education-specific associations between large pictorial warnings and smoking prevalence, and whether such association differed by education was examined using an interaction test. Results: At the time of the survey, eight out of 18 countries had imposed graphic warning labels that covered ≥50% of the package. These warnings were associated with a 10.0% (OR = 0.89; 95% CI: 0.81, 0.97; p ≤ 0.01) lower cigarette smoking prevalence among adults with less than a secondary education or no formal education, but not among respondents with at least a secondary education. Less educated respondents were also less likely to be exposed to warnings in all 18 countries. The association between strong warnings and lower smoking prevalence among less educated respondents could be greater if their exposure to warnings increases. Conclusions: Prominent pictorial warning labels can potentially reduce health disparities resulting from smoking across different education levels.

Prevalence and determinants of current and secondhand smoking in Greece: results from the Global Adult Tobacco Survey (GATS) study

OBJECTIVES

Greece is one of the leading tobacco-producing countries in European Union, and every year over 19 000 Greeks die from tobacco-attributable diseases. The aim of the present study was to provide nationally representative estimates on current and secondhand smoking prevalence in Greece and their determinants.

DESIGN

Cross-sectional.

SETTING

Greece.

PARTICIPANTS

A total of 4359 individuals participated in the Global Adult Tobacco Survey (GATS), a household survey of adults ≥15 years old (overall response rate 69%). They were selected through a multistage geographically clustered sampling design with face-to-face interview.

PRIMARY AND SECONDARY OUTCOME MEASURES

In 2013, we investigated the prevalence of current and secondhand smoking and their determinants. Univariate and logistic regression analysis was used in order to identify possible risk factors associated with the prevalence of current and secondhand smoking.

RESULTS

The prevalence of current smoking was 38.2% (95% CI 35.7% to 40.8%), and the mean number of cigarettes smoked per day was 19.8. Multivariate analysis confirmed that male gender (OR=3.24; 95% CI 2.62 to 4.00), age groups (25-39, OR=4.49; 95% CI 3.09 to 8.46 and 40-54, OR=3.51; 95% CI 1.88 to 5.87) and high school education (OR=1.97; 95% CI 1.41 to 2.74) were independently associated with the current smoking. Remarkably, responders with primary or less education had the lowest prevalence of current smoking (p<0.001). The prevalence of exposure to secondhand smoke at work, home and restaurants, was 52.3%, 65.7% and 72.2%. In total, 90.0% (95% CI 87.8% to 91.9%) of Greek population is exposed to tobacco smoke (current smoking and secondhand smoke).

CONCLUSIONS

Our results revealed an extremely high prevalence of current smoking and exposure to secondhand smoke among the adult population and a positive gradient between education and current smoking. These findings are alarming and implementation of comprehensive tobacco control and prevention strategies could be impactful in fighting the tobacco epidemic in Greece.

Socioeconomic Disparities in Age of Initiation and Ever Tobacco Smoking: Findings from Romania

AIM

Smoking initiation is considered the fundamental behaviour that determines the future health burden of tobacco smoking in a society. The aim of the study was to evaluate the socio-demographic factors associated with initiation of regular smoking among adults.

METHODS

The data source was the 2011 Global Adult Tobacco Survey Romania (GATS), which is a cross-sectional, nationally representative study. Multivariate logistic regression model was applied for relevant analysis.

RESULTS

Among males, the regular smoking initiation rate was significantly higher compared to females (52.4% vs. 18.5%; p<0.001). Mean age of smoking initiation was lower in men compared to women (18.4±4.8 vs. 21.5±6.8; p<0.001). Age in men, awareness of environmental tobacco smoke consequences and place of living for women as well as educational attainment and employment status in both genders were associated with ever regular smoking. Moreover, cohabitation with a smoker was associated with greater odds for initiating smoking among both genders.

CONCLUSIONS

GATS revealed a significant but diverse role of socioeconomic factors in initiation of regular smoking among adult Romanians.

Heaviness of smoking among employed men and women in Poland

OBJECTIVES

At least 50% of smokers die prematurely. Those who smoke heavily are at an increased health risk. The purpose of the current report was to evaluate socio-demographic correlates of heavy smoking among employed men and women.

MATERIAL AND METHODS

Data derive from the representative, household study - the Global Adult Tobacco Survey conducted in Poland over the years 2008-2010.

RESULTS

Of 14 000 households selected for the survey, 7840 sampled individuals completed the interviews. Among 1189 daily smokers, the rate of heavy smokers was 63.5% in males and 43% in employed females (p < 0.001). The study showed that age and age at the smoking onset were significantly associated with heavy smoking among both genders. Among males and females the heavy smoking rate was the highest in the subjects that started smoking at the age between 14-17 years compared to those who started smoking at the age ≥ 21 years (odds ratio (OR) = 3.3, 95% confidence interval (CI): 2-5.5, p < 0.001 and OR = 2.7, 95% CI: 1.4-5.3, p < 0.0001, respectively). The men with house rules that prohibited smoking with some exceptions were 2.4 times more likely to be heavy smokers in comparison with those having rules which completely prohibited it (p < 0.01). The men working in workplaces where smoking was prohibited in all indoor areas were at lower odds of heavy smoking relative to those working in areas where smoking was allowed everywhere (OR = 0.5, 95% CI: 0.3-0.9, p < 0.05). Among the men, there was also an association between job features and heavy smoking, which was not observed among the women.

CONCLUSIONS

These findings should be taken into account while developing tobacco control measures addressed to economically active population.

Trends and structural shifts in health tourism: evidence from seasonal time-series data on health-related travel spending by Canada during 1970-2010

There has been a growing interest in better understanding the trends and determinants of health tourism activities. While much of the expanding literature on health tourism offers theoretical or qualitative discussion, empirical evidences has been lacking. This study employs Canada's outbound health tourism activities as an example to examine the trends in health tourism and its association with changing domestic health care market characteristics. A time-series model that accounts for potential structural changes in the trend is employed to analyze the quarterly health-related travel spending series reported in the Balance of Payments Statistics (BOPS) during 1970-2010 (n = 156). We identified a structural shift point which marks the start of an accelerated growth of health tourism and a flattened seasonality in such activities. We found that the health tourism activities of Canadian consumers increase when the private investment in medical facilities declines or when the private MPI increases during the years following the structural-change. We discussed the possible linkage of the structural shift to the General Agreement on Trade in Services (GATS), which went into effect in January, 1995.

"Why not stoichiometry" versus "stoichiometry--why not?" Part I: General context

The elementary concepts involved with stoichiometry are considered from different viewpoints. Some examples of approximate calculations made according to the stoichiometric scheme are indicated, and correct resolution of the problems involved is presented. The principles of balancing chemical equations, based on their apparent similarities with algebraic equations, are criticized. The review concerns some peculiarities inherent in chemical reaction notation and its use (and abuse) in stoichiometric calculations that provide inconsistent results for various reasons. This "conventional" approach to stoichiometry is put in context with the generalized approach to electrolytic systems (GATES) established by Michałowski. The article contains a number of proposals that could potentially be taken into account and included in the next edition of the Orange Book. Notation of ions used in this article is not, deliberately, in accordance with actual IUPAC requirements in this respect. This article is intended to be provocative with the hope that some critical debate around the important topics treated should be generated and creatively expanded in the scientific community.

Association between being employed in a smoke-free workplace and living in a smoke-free home: evidence from 15 low and middle income countries

OBJECTIVE

To assess whether being employed in a smoke-free workplace is associated with living in a smoke-free home in 15 low and middle income countries (LMICs).

METHODS

Country-specific individual level analyses of cross-sectional Global Adult Tobacco Survey data (2008-2011) from 15 LMICs was conducted using multiple logistic regression. The dependent variable was living in a smoke-free home; the independent variable was being employed in a smoke-free workplace. Analyses were adjusted for age, gender, residence, region, education, occupation, current smoking, current smokeless tobacco use and number of household members. Individual country results were combined in a random effects meta-analysis.

RESULTS

In each country, the percentage of participants employed in a smoke-free workplace who reported living in a smoke-free home was higher than those employed in a workplace not smoke-free. The adjusted odds ratios (AORs) of living in a smoke-free home among participants employed in a smoke-free workplace (vs. those employed where smoking occurred) were statistically significant in 13 of the 15 countries, ranging from 1.12 [95% CI 0.79-1.58] in Uruguay to 2.29 [1.37-3.83] in China. The pooled AOR was 1.61 [1.46-1.79].

CONCLUSION

In LMICs, employment in a smoke-free workplace is associated with living in a smoke-free home. Accelerated implementation of comprehensive smoke-free policies is likely to result in substantial population health benefits in these settings.

Urbanization and international trade and investment policies as determinants of noncommunicable diseases in Sub-Saharan Africa

There are three dominant globalization pathways affecting noncommunicable diseases in Sub-Saharan Africa (SSA): urbanization, trade liberalization, and investment liberalization. Urbanization carries potential health benefits due to improved access to an increased variety of food imports, although for the growing number of urban poor, this has often meant increased reliance on cheap, highly processed food commodities. Reduced barriers to trade have eased the importation of such commodities, while investment liberalization has increased corporate consolidation over global and domestic food chains. Higher profit margins on processed foods have promoted the creation of ‘obesogenic’ environments, which through progressively integrated global food systems have been increasingly ‘exported’ to developing nations. This article explores globalization processes, the food environment, and dietary health outcomes in SSA through the use of trend analyses and structural equation modelling. The findings are considered in the context of global barriers and facilitators for healthy public policy.

Liberalising trade in health services: constraints and prospects for South Asian countries

This paper attempts to examine the prospects and challenges associated with liberalising trade in health services in five South Asian countries, namely Bangladesh, India, Nepal, Pakistan and Sri Lanka. Country-specific secondary information, a brief literature review of empirical studies and debriefing sessions with key stakeholders are employed to explore the issues related to liberalising health services trade. The health sectors in India, Nepal and Pakistan are scheduled under General Agreement on Trade in Services (GATS) classification, whereas those in Bangladesh and Sri Lanka are not. In Bangladesh, there is opportunity for investment in joint venture hospitals under Mode 3. Nonetheless, India is the largest trader in health services under all four modes. In Sri Lanka, cross-border trade in healthcare services is found to be insignificant. Moreover, expertise in eye treatment in Nepal could also attract foreign investment in medical services under Mode 3. In contrast, Pakistan exhibits no potential under Mode 4, because of a lack of healthcare professionals. In this view, the prospects of trade in health services within the South Asian region under the four GATS modes are constrained by infrastructural, regulatory, perception-related, logistical and cultural problems. Considering the level of development and commercial opportunities, regional integration in the health sector could be explored in such areas as telemedicine, medical tourism, cross-border investment and capacity building of health personnel. These developments call for stronger and pro-active government-to-government collaboration in the South Asian Association of Regional Cooperation (SAARC) region in a transparent and accountable manner.