The collateral damage of COVID-19 to cardiovascular services: a meta-analysis

AIMS

The effect of the COVID-19 pandemic on care and outcomes across non-COVID-19 cardiovascular (CV) diseases is unknown. A systematic review and meta-analysis was performed to quantify the effect and investigate for variation by CV disease, geographic region, country income classification and the time course of the pandemic.

METHODS AND RESULTS

From January 2019 to December 2021, Medline and Embase databases were searched for observational studies comparing a pandemic and pre-pandemic period with relation to CV disease hospitalisations, diagnostic and interventional procedures, outpatient consultations, and mortality. Observational data were synthesised by incidence rate ratios (IRR) and risk ratios (RR) for binary outcomes and weighted mean differences for continuous outcomes with 95% confidence intervals. The study was registered with PROSPERO (CRD42021265930). A total of 158 studies, covering 49 countries and 6 continents, were used for quantitative synthesis. Most studies (80%) reported information for high-income countries (HICs). Across all CV disease and geographies there were fewer hospitalisations, diagnostic and interventional procedures, and outpatient consultations during the pandemic. By meta-regression, in low-middle income countries (LMICs) compared to HICs the decline in ST-segment elevation myocardial infarction (STEMI) hospitalisations (RR 0.79, 95% confidence interval [CI] 0.66-0.94) and revascularisation (RR 0.73, 95% CI 0.62-0.87) was more severe. In LMICs, but not HICs, in-hospital mortality increased for STEMI (RR 1.22, 95% CI 1.10-1.37) and heart failure (RR 1.08, 95% CI 1.04-1.12). The magnitude of decline in hospitalisations for CV diseases did not differ between the first and second wave.

CONCLUSIONS

There was substantial global collateral CV damage during the COVID-19 pandemic with disparity in severity by country income classification.

Data gaps towards health development goals, 47 low- and middle-income countries

Objective

To assess the availability and gaps in data for measuring progress towards health-related sustainable development goals and other targets in selected low- and middle-income countries.

Methods

We used 14 international population surveys to evaluate the health data systems in the 47 least developed countries over the years 2015–2020. We reviewed the survey instruments to determine whether they contained tools that could be used to measure 46 health-related indicators defined by the World Health Organization. We recorded the number of countries with data available on the indicators from these surveys.

Findings

Twenty-seven indicators were measurable by the surveys we identified. The two health emergency indicators were not measurable by current surveys. The percentage of countries that used surveys to collect data over 2015–2020 were lowest for tuberculosis (2/47; 4.3%), hepatitis B (3/47; 6.4%), human immunodeficiency virus (11/47; 23.4%), child development status and child abuse (both 13/47; 27.7%), compared with safe drinking water (37/47; 78.7%) and births attended by skilled health personnel (36/47; 76.6%). Nineteen countries collected data on 21 or more indicators over 2015–2020 while nine collected data on no indicators; over 2018–2020 these numbers reduced to six and 20, respectively.

Conclusion

Examining selected international surveys provided a quick summary of health data available in the 47 least developed countries. We found major gaps in health data due to long survey cycles and lack of appropriate survey instruments. Novel indicators and survey instruments would be needed to track the fast-changing situation of health emergencies.

Une étude de corrélations entre la sévérité clinique et l’intensité de l’inflammation

Introduction

Le coronavirus 19 peut être à l’origine d’un spectre varié de manifestations cliniques. Le défi actuel est de déterminer des biomarqueurs fiables pour identifier les formes sévères.

Méthodes

C’est une étude prospective, longitudinale, incluant 143 patients infectés par le SARS2-COVID (confirmés par une PCR), admis au service de pneumologie de l’hôpital militaire, entre le mois de septembre 2020 et le mois de janvier 2021. Ils ont bénéficié d’un examen, d’un bilan sanguin, d’un scanner thoracique et d’un test PCR.

Résultats

Nous avons inclus 143 patients d’âge moyen de 62 ans, avec une nette prédominance masculine (69 %). Quant aux comorbidités, un diabète de type 2 était retrouvé dans (36 cas), une hypertension dans (56 cas), une insuffisance coronaire dans (5 cas), une dyslipidémie dans (28 cas) et une BPCO dans (8 cas). Une obésité morbide était retrouvée dans (38 cas). La fièvre était le motif principal de consultation (91 cas [64,1 %]). Par ailleurs, les frissons ont été rapportés dans 35 cas (24,5 %), un syndrome grippal dans 59 cas (41,3 %), une anosmie-agueusie dans 23 cas (16,1 %) et des troubles digestifs (une diarrhée dans 30 cas [21 %] et des vomissements dans 17 cas [12 %]). Donc, l’infection était donc classée comme : minime chez 33 patients (25,8 %), modérée chez 25 patients (19,5 %), sévère chez 60 patients (46,9 %) et critique chez 10 patients (7,8 %). Concernant les données biologiques, une hyperleucocytose était notée dans 36 cas (25 %). La CRP était élevée dans 108 cas (75,52 %). Les D-Dimères étaient élevées dans 117 cas (81,81 %). Le fibrinogène était élevé dans 12 cas (8,4 %). L’interleukine 6 étaient élevée dans 6 cas (4,2 %). Il est pertinent de noter qu’il existe une forte corrélation entre la sévérité clinique et le tabagisme (p = 0,033), l’obésité (p = 0,023), la présence d’une insuffisance cardiaque (p = 0,02) ou d’une néoplasie préexistante (p = 0,01) et l’intensité de l’inflammation (CRP [p = 0,031], fibrinogène [p = 0,011]). Concernant le traitement, une antibiothérapie était prescrite chez 135 cas (95,4 %). De plus, certains cas ont nécessité le recours à : la VNI (14 cas) ou à l’Optiflow (9 cas). Une intubation trachéale était pratiquée dans (3 cas). Par ailleurs, 23 cas ont présenté des complications nécessitant le transfert en réanimation. Nous rapportons désormais 13 cas de décès.

Conclusion

Notre étude soutient l’hypothèse d’une inflammation « auto-entretenue » chez les patients atteints du COVID-19 à l’origine d’un pronostic plus péjoratif.

A call to strengthen data in response to COVID-19 and beyond

The COVID-19 (coronavirus disease 2019) pandemic has underscored the critical need for all countries to strengthen their health data and information systems and ensure the routes the data travel, from submission to use, are unobstructed. Timely, credible, reliable, and actionable data are key to ensuring that political decisions are data driven and facilitate understanding, monitoring, and forecasting. To ensure that critical decisions related to the wider health and socioeconomic effects of this pandemic are data driven, each country needs to develop or enhance a national data governance plan that includes a clear coordination mechanism, well-defined and documented data processes (manual or electronic), the exchange of data, and a data culture to empower users. In addition, countries should now more than ever invest and enhance their data and health information systems to ensure that all decisions are data driven and that they are prepared for what is next.

Access to Cardiovascular Disease and Hypertension Medicines in Developing Countries: An Analysis of Essential Medicine Lists, Price, Availability, and Affordability

Background Access to medicines is important for long-term care of cardiovascular diseases and hypertension. This study provides a cross-country assessment of availability, prices, and affordability of cardiovascular disease and hypertension medicines to identify areas for improvement in access to medication treatment. Methods and Results We used the World Health Organization online repository of national essential medicines lists (EMLs) for 53 countries to transcribe the information on the inclusion of 12 cardiovascular disease/hypertension medications within each country's essential medicines list. Data on availability, price, and affordability were obtained from 84 surveys in 59 countries that used the World Health Organization's Health Action International survey methodology. We summarized and compared the indicators across lowest-price generic and originator brand medicines in the public and private sectors and by country income groups. The average availability of the select medications was 54% in low- and lower-middle-income countries and 60% in high- and upper-middle-income countries, and was higher for generic (61%) than brand medicines (41%). The average patient median price ratio was 80.3 for brand and 16.7 for generic medicines and was higher for patients in low- and lower-middle-income countries compared with high- and upper-middle-income countries across all medicine categories. The costs of 1 month's antihypertensive medications were, on average, 6.0 days' wage for brand medicine and 1.8 days' wage for generics. Affordability was lower in low- and lower-middle-income countries than high- and upper-middle-income countries for both brand and generic medications. Conclusions The availability and accessibility of pharmaceuticals is an ongoing challenge for health systems. Low availability and high costs are major barriers to the use of and adherence to essential cardiovascular disease and antihypertensive medications worldwide, particularly in low- and lower-middle-income countries.

Global Surveillance of trans-Fatty Acids

Trans-fatty acid (TFA) intake can increase the risk of coronary heart disease (CHD) morbidity and mortality and all-cause mortality. Industrially produced TFAs and ruminant TFAs are the major sources in foods. TFA intake and TFA-attributed CHD mortality vary widely worldwide. Excessive TFA intake is a health threat in high-income countries; however, it is also a threat in low- and middle-income countries (LMICs). Data on TFA intake are scarce in many LMICs and an urgent need exists to monitor TFAs globally. We reviewed global TFA intake and TFA-attributed CHD mortality and current progress toward policy or regulation on elimination of industrially produced TFAs in foods worldwide. Human biological tissues can be used as biomarkers of TFAs because they reflect actual intake from various foods. Measuring blood TFA levels is a direct and reliable method to quantify TFA intake.

Assessing the relationship between out-of-pocket spending on blood pressure and diabetes medication and household catastrophic health expenditure: evidence from Pakistan

Background

Treatment of non-communicable diseases (NCDs) in low-and-middle-income countries (LMICs) is costly and could expose households to financial hardship and vulnerability. This paper examines the association between medication costs of two major NCDs – hypertension (blood pressure) and diabetes, and household-level incidences of catastrophic health expenditure (CHE) in a South Asian LMIC, Pakistan.

Methods

The study analyzes self-reported blood pressure and diabetes (BPD) medication expenditure from the latest version (2015–16) of the Household Integrated Economic Survey (HIES) of Pakistan, a nationally representative survey of 24,238 households. The incidence of CHE is defined as households’ out-of-pocket (OOP) medical expenditure exceeding 10% of the total household expenditure. Using a linear probability model, we estimate the adjusted differences in CHE incidence between households that are spending and ‘not’ spending on BPD medication. We also analyze several hypothetical scenarios of BPD medication cost coverage, and compare the estimated CHE incidences of respective scenarios with the status quo.

Results

We find that the average monthly medical expenditure, and average medical expenditure share are significantly higher for households spending on BPD medication, compared to households ‘not’ spending. The incidence of CHE is found 6.7 percentage point higher for the households consuming BPD medication, after controlling for relevant socioeconomic attributes. If 25, 50, and 100% of the BPD medication OOP cost is covered, then the CHE incidence would reduce respectively by 5.9, 12.7, and 21.4% compared to the status quo.

Conclusion

Medication cost for managing two major NCDs and household catastrophic health expenditure have strong associations. The findings inform policies toward ensuring access to necessary healthcare services, and protecting households from NCD treatment related financial hardship.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0906-x) contains supplementary material, which is available to authorized users.

Synergies between Communicable and Noncommunicable Disease Programs to Enhance Global Health Security

Noncommunicable diseases are the leading cause of death and disability worldwide. Initiatives that advance the prevention and control of noncommunicable diseases support the goals of global health security in several ways. First, in addressing health needs that typically require long-term care, these programs can strengthen health delivery and health monitoring systems, which can serve as necessary platforms for emergency preparedness in low-resource environments. Second, by improving population health, the programs might help to reduce susceptibility to infectious outbreaks. Finally, in aiming to reduce the economic burden associated with premature illness and death from noncommunicable diseases, these initiatives contribute to the objectives of international development, thereby helping to improve overall country capacity for emergency response.

[Improved Blood Pressure Control to Reduce Cardiovascular Disease Morbidity and Mortality: The Standardized Hypertension Treatment and Prevention Project]

Hypertension is the leading remediable risk factor for cardiovascular disease, affecting more than 1 billion people worldwide, and is responsible for more than 10 million preventable deaths globally each year. While hypertension can be successfully diagnosed and treated, only one in seven persons with hypertension have controlled blood pressure. To meet the challenge of improving the control of hypertension, particularly in low- and middle-income countries, the authors developed the Standardized Hypertension Treatment and Prevention Project, which involves a health systems-strengthening approach that advocates for standardized hypertension management using evidence-based interventions. These interventions include the use of standardized treatment protocols, a core set of medications along with improved procurement mechanisms to increase the availability and affordability of these medications, registries for cohort monitoring and evaluation, patient empowerment, team-based care (task shifting), and community engagement. With political will and strong partnerships, this approach provides the groundwork to reduce high blood pressure and cardiovascular disease-related morbidity and mortality.

Improved Blood Pressure Control to Reduce Cardiovascular Disease Morbidity and Mortality: The Standardized Hypertension Treatment and Prevention Project

Hypertension is the leading remediable risk factor for cardiovascular disease, affecting more than 1 billion people worldwide, and is responsible for more than 10 million preventable deaths globally each year. While hypertension can be successfully diagnosed and treated, only one in seven persons with hypertension have controlled blood pressure. To meet the challenge of improving the control of hypertension, particularly in low- and middle-income countries, the authors developed the Standardized Hypertension Treatment and Prevention Project, which involves a health systems-strengthening approach that advocates for standardized hypertension management using evidence-based interventions. These interventions include the use of standardized treatment protocols, a core set of medications along with improved procurement mechanisms to increase the availability and affordability of these medications, registries for cohort monitoring and evaluation, patient empowerment, team-based care (task shifting), and community engagement. With political will and strong partnerships, this approach provides the groundwork to reduce high blood pressure and cardiovascular disease-related morbidity and mortality.

Cigarette smoking and cigarette marketing exposure among students in selected African countries: Findings from the Global Youth Tobacco Survey

OBJECTIVE

To investigate cigarette smoking prevalence and exposure to various forms of cigarette marketing among students in 10 African countries.

METHODS

We used data collected during 2009-2011 from the Global Youth Tobacco Survey (GYTS), a school-based cross-sectional survey of students aged 13-15years, to measure the prevalence of cigarette smoking and exposure to cigarette marketing; comparisons to estimates from 2005 to 2006 were conducted for five countries where data were available.

RESULTS

Current cigarette smoking ranged from 3.4% to 13.6% among students aged 13-15 in the 10 countries studied, although use of tobacco products other than cigarettes was more prevalent in all countries except in Cote D'Ivoire. Cigarette smoking was higher among boys than girls in seven out of the 10 countries. Among the five countries with two rounds of surveys, a significant decrease in cigarette smoking prevalence was observed in Mauritania and Niger; these two countries also experienced a decline in three measures of cigarette marketing exposure. It is also possible that smoking prevalence might have risen faster among girls than boys.

CONCLUSION

Cigarette smoking among youth was noticeable in 10 African countries evaluated, with the prevalence over 10% in Cote D'Ivoire, Mauritania, and South Africa. Cigarette marketing exposure varied by the types of marketing; traditional venues such as TV, outdoor billboards, newspapers, and magazines were still prominent.

Secondhand smoke exposure and susceptibility to initiating cigarette smoking among never-smoking students in selected African countries: Findings from the Global Youth Tobacco Survey

BACKGROUND

Exposure to secondhand smoke (SHS) causes premature death and illness in non-smokers. We examined SHS exposure at home and in public places, as well as susceptibility to initiate cigarette smoking among never cigarette smokers. We used 2006-2011 Global Youth Tobacco Survey (GYTS) data from 29 African countries (56,967 students).

METHODS

GYTS is a nationally representative, self-administered school-based survey, conducted among students aged 13-15years. Prevalence ratio, estimates and 95% confidence intervals were computed for SHS exposure in the homes and public places separately. The two-sample t-test was used to assess the difference in susceptibility to smoking by SHS exposure among never-smoking students (α=0.05).

RESULTS

Among never-smoking students, exposure to SHS at home ranged from 12.7% (Cape Verde) to 44.0% (Senegal). The prevalence ratio (PR) comparing susceptibility to smoking initiation among never smokers exposed to SHS at home to those who were not exposed at home ranged from 1.2 to 2.6. Exposure to SHS in public places ranged from 23.9% (Cape Verde) to 80.4% (Mali). Of the countries being studied, 8 countries showed a significant difference in susceptibility to smoking initiation among never smokers exposed to SHS in public places compared to those not exposed in public places. (PR ranged from 0.5-3.5).

CONCLUSION

In many African countries in the study, a substantial proportion of students who never smoked are exposed to SHS at home and in public places. Majority of never smokers who were exposed to SHS at home and in public places had a higher prevalence of susceptibility to initiate smoking than those that were not exposed to SHS at home and in public places. Adoption and enforcement of smoke-free policies in public places and smoke-free rules at home could substantially contribute to reducing SHS exposure in many of these countries.

Awareness and Current Use of Electronic Cigarettes in Indonesia, Malaysia, Qatar, and Greece: Findings From 2011-2013 Global Adult Tobacco Surveys

INTRODUCTION

Increases in electronic cigarette (e-cigarette) awareness and current use have been documented in high income countries but less is known about middle and low income countries.

METHODS

Nationally representative household survey data from the first four Global Adult Tobacco Surveys to assess e-cigarettes were analyzed, including Indonesia (2011), Malaysia (2011), Qatar (2013), and Greece (2013). Correlates of e-cigarette awareness and current use were calculated. Sample sizes for Greece and Qatar allowed for further analysis of e-cigarette users.

RESULTS

Awareness of e-cigarettes was 10.9% in Indonesia, 21.0% in Malaysia, 49.0% in Qatar, and 88.5% in Greece. In all four countries, awareness was higher among male, younger, more educated, and wealthier respondents. Current e-cigarette use among those aware of e-cigarettes was 3.9% in Malaysia, 2.5% in Indonesia, 2.2% in Greece and 1.8% in Qatar. Across these four countries, an estimated 818 500 people are currently using e-cigarettes. Among current e-cigarette users, 64.4% in Greece and 84.1% in Qatar also smoked cigarettes, and, 10.6% in Greece and 6.0% in Qatar were never-smokers.

CONCLUSIONS

E-cigarette awareness and use was evident in all four countries. Ongoing surveillance and monitoring of awareness and use of e-cigarettes in these and other countries could help inform tobacco control policies and public health interventions. Future surveillance should monitor use of e-cigarettes among current smokers and uptake among never-smokers and relapsing former smokers.

Waterpipe Tobacco Smoking in Turkey: Policy Implications and Trends from the Global Adult Tobacco Survey (GATS)

Waterpipe tobacco smoking (WTS) is an emerging tobacco product globally, especially among adolescents and young adults who may perceive WTS as a safe alternative to smoking cigarettes. Monitoring the use of WTS in Turkey in relation to the tobacco control policy context is important to ensure that WTS does not become a major public health issue in Turkey. The Global Adult Tobacco Survey (GATS) was conducted in Turkey in 2008 and was repeated in 2012. GATS provided prevalence estimates on current WTS and change over time. Other indicators of WTS were also obtained, such as age of initiation and location of use. Among persons aged 15 and older in Turkey, the current prevalence of WTS decreased from 2.3% in 2008 to 0.8% in 2012, representing a 65% relative decline. Among males, WTS decreased from 4.0% to 1.1% (72% relative decline). While the overall smoking prevalence decreased among females, there was no change in the rate of WTS (0.7% in 2008 vs. 0.5% in 2012), though the WTS prevalence rate was already low in 2008. Comprehensive tobacco control efforts have been successful in reducing the overall smoking prevalence in Turkey, which includes the reduction of cigarette smoking and WTS. However, it is important to continue monitoring the use of waterpipes in Turkey and targeting tobacco control efforts to certain groups that may be vulnerable to future WTS marketing (e.g., youth, women).

The Process of Cessation Among Current Tobacco Smokers: A Cross-Sectional Data Analysis From 21 Countries, Global Adult Tobacco Survey, 2009-2013

We analyzed data from the Global Adult Tobacco Survey (GATS) from 21 countries to categorize smokers by stages of cessation and highlight interventions that could be tailored to each stage. GATS is a nationally representative household survey that measures tobacco use and other key indicators by using a standardized protocol. The distribution of smokers into precontemplation, contemplation, and preparation stages varied by country. Using the stages of change model, each country can design and implement effective interventions suitable to its cultural, social, and economic situations to help smokers advance successfully through the stages of cessation.

Levels and trends of smokeless tobacco use among youth in countries of the World Health Organization South-East Asia Region

BACKGROUND

At least two rounds of the Global Youth Tobacco Survey (GYTS) have been completed in most of the countries in the World Health Organization South-East Asia region. Comparing findings from these two rounds provides trend data on smokeless tobacco (SLT) use for the first time.

METHODS

This study uses GYTS data from Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste during 2006-2013. GYTS is a nationally representative survey of 13-15-year-old students using a consistent and standard protocol. Current SLT use is defined as using any kind of SLT products, such as chewing betel quid or nonbetel quid or snuffing any other products orally or through the nasal route, during the 30 days preceding the survey. Prevalence and 95% confidence intervals were computed using SAS/SUDAAN software.

RESULTS

According to most recent GYTS data available in each country, the prevalence of current use of SLT among youth varied from 5.7% in Thailand to 23.2% in Bhutan; among boys, from 7.1% in Bangladesh to 27.2% in Bhutan; and among girls, from 3.7% in Bangladesh to 19.8% in Bhutan. Prevalence of SLT was reported significantly higher among boys than girls in Bhutan (boys 27.2%; girls 19.8%), India (boys 11.1%; girls 6.0%), Maldives (boys 9.2%; girls 2.9%), Myanmar (boys 15.2%; girls 4.0%), and Sri Lanka (boys 13.0%; girls 4.1%). Prevalence of current SLT use increased in Bhutan from 9.4% in 2009 to 23.2% in 2013, and in Nepal from 6.1% in 2007 to 16.2% in 2011.

CONCLUSION

The findings call for countries to implement corrective measures through strengthened policy and enforcement.

Smokeless tobacco use: a meta-analysis of risk and attributable mortality estimates for India

BACKGROUND

Use of smokeless tobacco (SLT) is widely prevalent in India and Indian subcontinent. Cohort and case-control studies in India and elsewhere report excess mortality due to its use.

OBJECTIVE

The aim was to estimate the SLT use-attributable deaths in males and females, aged 35 years and older, in India.

MATERIALS AND METHODS

Prevalence of SLT use in persons aged 35 years and older was obtained from the Global Adult Tobacco Survey in India and population size and deaths in the relevant age-sex groups were obtained from UN estimates (2010 revision) for 2008. A meta-relative risk (RR) based population attributable fraction was used to estimate attributable deaths in persons aged 35 years and older. A random effects model was used in the meta-analysis on all-cause mortality from SLT use in India including four cohort and one case-control study. The studies included in the meta-analysis were adjusted for smoking, age and education.

RESULTS

The prevalence of SLT use in India was 25.2% for men and 24.5% for women aged 35 years and older. RRs for females and males were 1.34 (1.27-1.42) and 1.17 (1.05-1.42), respectively. The number of deaths attributable to SLT use in India is estimated to be 368127 (217,076 women and 151,051 men), with nearly three-fifth (60%) of these deaths occurring among women.

CONCLUSION

SLT use caused over 350,000 deaths in India in 2010, and nearly three-fifth of SLT use-attributable deaths were among women in India. This calls for targeted public health intervention focusing on SLT products especially among women.

Effectiveness of fludarabine- and busulfan-based conditioning regimens in patients with acute myeloblastic leukemia: 8-year experience in a single center

OBJECTIVE

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a curative treatment for acute myeloblastic leukemia (AML). Because the conditioning regimen of busulfan plus cyclophosphamide carries significant risks of toxicity, we evaluated the factors affecting survival after fludarabine replacement instead of cyclophosphamide.

METHODS

The study included 55 patients who underwent allo-HSCT for AML and received busulfan, fludarabine, and antithymocyte globulin (ATG).

RESULTS

Forty-eight patients received a myeloablative regimen; 7 patients received a reduced-intensity conditioning regimen. The neutrophil and platelet engraftment times were 12 days (range 9 to 20) and 12 days (range 7 to 19), respectively. Graft-vs-host disease (GvHD) developed in 10% and 50% of the patients, respectively. Seven patients received donor lymphocyte infusion. Of them, 5 patients developed grade I or II GvHD, one grade IV GvHD. The median follow-up period was 20.6 months. The predicted progression-free survival (PFS) at 1 and 3 years after transplantation was 78% and 74%, respectively. The overall survival (OS) at 1, 3, and 5 years was 76%, 74%, and 62%, respectively. Treatment-related mortality (infection in 1 patient, GvHD in 2 patients) occurred in 3 patients (5.5%). Multivariate analysis revealed that OS and PFS were not influenced by age, dose of busulfan or ATG, or presence of cytomegalovirus antigenemia. Acute GvHD and pretransplantation minimal residual disease positivity negatively affected the transplant outcome. The presence of active disease at the time of transplantation was found as an independent risk factor for AML.

CONCLUSIONS

Busulfan- and fludarabine-based conditioning regimens are effective for AML, and have acceptable toxicity, morbidity, and mortality.

Warning about the harms of tobacco use in 22 countries: findings from a cross-sectional household survey

BACKGROUND

Knowledge about the harms of tobacco use deters initiation and is associated with cessation. Most studies on this knowledge in the general population have been in high-income countries, but the tobacco use burden is increasing in low-income and middle-income countries. We sought to estimate levels of knowledge about tobacco-related diseases in 22 countries and determine the factors associated with differences in knowledge.

METHODS

We used data from the Global Adult Tobacco Survey (GATS), a nationally representative survey of persons aged ≥15 years. GATSs were conducted from 2008 to 2013 in 22 low-income and middle-income countries. Information was gathered on tobacco-related knowledge and noticing of antismoking mass media messages and health warning labels on cigarette packages. We constructed a four-point knowledge scale and performed multivariate regression analyses.

RESULTS

Median country values for the proportion of adults who believed smoking causes a specific illness were 95.9% for lung cancer, 82.5% for heart attack and 74.0% for stroke. Knowledge scores ranged from 2.1 to 3.8. In multivariate regressions, adults scored significantly higher on the knowledge scale if they noticed antismoking media messages (22 countries) or health warning labels (17 countries). Significantly higher knowledge scores occurred in all 9 countries with pictorial health warning labels compared with only 8 out of 13 countries with text-only warning labels.

CONCLUSIONS

Antismoking media messages appear effective for warning the public about the harms from tobacco use in all 22 countries, while warning labels are effective in the majority of these countries. Our findings suggest opportunities to motivate smoking cessation globally.

A Cross Sectional Study of Kretek Smoking in Indonesia as a Major Risk to Public Health

BACKGROUND

Tobacco smoking is a major cause of preventable disease and death worldwide. Kreteks are clove-flavored cigarettes made from a combination of tobacco and ground-clove mixed with a sauce, smoked widely in Indonesia. Because health and social consequences of kretek smoking are potentially as great as those of traditional cigarettes, this study examines the prevalence of kretek smoking in Indonesia and associated risk factors.

MATERIALS AND METHODS

The study used nationally representative Indonesia Global Adult Tobacco Survey data. Multiple logistic regression analysis was employed to identify correlates of kretek smoking.

RESULTS

One- third of Indonesian adults smoked tobacco of which about 90.0% smoked kreteks. Prevalence of kretek smoking among men (60.9%) was more than 25 times the rate among women (2.3%). Overall, the highest prevalence of kretek use was in the age group 45-54 years (36.5%), followed by 34-44 (35.1%), 25-34 (34.2 %), and 55-64 years (32.8%). By wealth index, prevalence of kreteks smoking among those in the middle index was almost 50% above the rate for the wealthiest group (36.4% vs 24.8% respectively). Logistic regression results showed that being male, being older, having less education, and being less wealthy were significant predictors of kretek smoking, while urban vs rural residence was not.

CONCLUSIONS

Kretek smoking is common in Indonesia and is entrenched in the sociocultural fabric of the country. However, potential consequences of kretek smoking, particularly as risks for noncommunicable diseases, underscore the importance of a comprehensive approach to tobacco control as outlined in the World Health Organization's MPOWER strategies.

Influence of tobacco industry advertisements and promotions on tobacco use in India: findings from the Global Adult Tobacco Survey 2009-2010

INTRODUCTION

The developing world, including countries like India, has become a major target for the tobacco industry to market its products. This study examines the influence of the marketing (advertising and promotion) of tobacco products on the use of tobacco by adults (ages 15 and over) in India.

METHOD

Data from Global Adult Tobacco Survey 2009-2010 was analyzed using methods for complex (clustered) sample designs. Multivariate logistic regression was employed to predict the use of different tobacco products by level of exposure to tobacco marketing using adults who have never used tobacco as the reference category. Odds ratios (ORs) were adjusted for education, gender, age, state of residence, wealth index, and place of residence (urban/rural).

RESULTS

Adults in India were almost twice as likely to be current smokers (versus never users) when they were exposed to a moderate level of bidi or cigarette marketing. For bidis, among adults with high exposure, the OR for current use was 4.57 (95% confidence interval [CI]: 1.6, 13.0). Adults were more likely to be current users of smokeless tobacco (SLT) with even a low level of exposure to SLT marketing (OR = 1.24 [95% CI: 1.1, 1.4]). For SLT, the ORs showed an increasing trend (P for trend < 0.001) with greater level of exposure (moderate, OR = 1.55 [95% CI: 1.1, 2.2]; high, OR = 2.05 [95% CI: 0.8, 5.1]). The risk of any current tobacco use rose with increasing level of exposure to any marketing (minimum, OR = 1.25 [1.1-1.4]; moderate, OR = 1.38 [1.1-1.8]; and high, OR = 2.73 [1.8-4.2]), with the trend highly significant (P < 0.001).

CONCLUSION

Exposure to the marketing of tobacco products, which may take the form of advertising at the point of sale, sales or a discounted price, free coupons, free samples, surrogate advertisements, or any of several other modalities, increased prevalence of tobacco use among adults. An increasing level of exposure to direct and indirect advertisement and promotion is associated with an increased likelihood of tobacco use.

Prevalence and sociodemographic determinants of tobacco use in four countries of the World Health Organization: South-East Asia region: findings from the Global Adult Tobacco Survey

INTRODUCTION

Tobacco use is a leading cause of deaths and Disability Adjusted Life Years lost worldwide, particularly in South-East Asia. Health risks associated with exclusive use of one form of tobacco alone has a different health risk profile when compared to dual use. In order to tease out specific profiles of mutually exclusive categories of tobacco use, we carried out this analysis.

METHODS

The Global Adult Tobacco Survey (GATS) data was used to describe the profiles of three mutually exclusive tobacco use categories ("Current smoking only," "Current smokeless tobacco [SLT] use only," and "Dual use") in four World Health Organization South-East Asia Region countries, namely Bangladesh, India, Indonesia and Thailand. GATS was a nationally representative household-based survey that used a stratified multistage cluster sampling design proportional to population size. Prevalence of different forms of usage were described as proportions. Logistics regression analyses was performed to calculate odds ratios (OR) with 95% confidence intervals. All analyses were weighted, accounted for the complex sampling design and conducted using SPSS version 18.

RESULTS

The prevalence of different forms of tobacco use varied across countries. Current tobacco use ranged from 27.2% in Thailand to 43.3% in Bangladesh. Exclusively smoking was more common in Indonesia (34.0%) and Thailand (23.4%) and less common in Bangladesh (16.1%) and India (8.7%). Exclusively using SLT was more common in Bangladesh (20.3%) and India (20.6%) and less common on Indonesia (0.9%) and Thailand (3.5%). Dual use of smoking and SLT was found in Bangladesh (6.8%) and India (5.3%), but was negligible in Indonesia (0.8) and Thailand (0.4%). Gender, age, education and wealth had significant effects on the OR for most forms of tobacco use across all four countries with the exceptions of SLT use in Indonesia and dual use in both Indonesia and Thailand. In general, the different forms of tobacco use increased among males and with increasing age; and decreased with higher education and wealth. The results for urban versus rural residence were mixed and frequently not significant once controlling for the other demographic factors.

CONCLUSION

This study addressed the socioeconomic disparities, which underlie health inequities due to tobacco use. Tobacco control activities in these countries should take in account local cultural, social and demographic factors for successful implementation.

Exploring the relationship between cigarette prices and smoking among adults: a cross-country study of low- and middle-income nations

INTRODUCTION

Evidence on the relationship between cigarette prices and adult smoking in low- and middle-income countries (LMICs) is relatively limited. This study offers new descriptive evidence on this relationship using data from a set of 13 LMICs.

METHODS

We use Global Adult Tobacco Survey (GATS) cross-country data from approximately 200,000 participants aged 15 and older. Estimates on the relationship between prices and adult smoking were obtained from logit models of smoking participation and ordinary least squares models of conditional cigarette demand.

RESULTS

Higher prices were associated with lower demand across countries, in terms of both smoking prevalence and daily number of cigarettes smoked among smokers. Our estimates suggest that the total price elasticity of cigarette demand in LMICs is approximately -0.53. We find that higher socioeconomic status (SES), represented through wealth and education effects is associated with lower chance of smoking overall, but among existing smokers, it may be associated with a larger number of cigarettes smoked.

CONCLUSIONS

After controlling for a set of individual demographic and country characteristics, cigarette prices retain a significant role in shaping cigarette demand across LMICs. Because higher SES is associated with a reduced chance of smoking overall but also with increased daily consumption among current smokers, optimal tobacco tax policies in LMICs may face an added need to accommodate to shifting SES structures within the populations of these countries.

Relationship between frequency and intensity of cigarette smoking and TTFC/C among students of the GYTS in select countries, 2007-2009

BACKGROUND

This study assessed the construct validity of a measure of nicotine dependence that was used in the Global Youth Tobacco Survey (GYTS).

METHODS

Using 2007-2009 data from the GYTS, subjects from 6 countries were used to assess current smokers' odds of reporting time to first cigarette or craving positive (TTFC/C+) by the number of cigarette smoking days per month (DPM) and the number of cigarettes smoked per day (CPD).

RESULTS

The percentage of GYTS smokers who reported TTFC/C+ ranged from 58.0% to 69.7%. Compared with students who smoked on 1-2 DPM, those who smoked on 3-9 DPM had 3 times the adjusted odds of reporting TTFC/C+. The adjusted odds of reporting TTFC/C+ were 3 to 7 times higher among those who smoked 10-29 DPM and 6 to 20 times higher among daily smokers. Similarly, the adjusted odds of TTFC/C+ were 3-6 times higher among those who smoked 2-5 CPD and 6 to 20 times higher among those who smoked >6 CPD, compared to those who smoked <1 CPD.

CONCLUSION

Associations of TTFC/C+ prevalence with both frequency and intensity of cigarette smoking provide a construct validation of the GYTS question used to assess respondents' TTFC/C status.

Cigarette prices and smoking prevalence after a tobacco tax increase--Turkey, 2008 and 2012

Raising the price of tobacco products has been shown to reduce tobacco consumption in the United States and other high-income countries, and evidence of this impact has been growing for low- and middle-income countries as well. Turkey is a middle-income country surveyed by the Global Adult Tobacco Survey (GATS) twice in a 4-year period, in 2008 and 2012. During this time, the country introduced a policy raising its Special Consumption Tax on Tobacco and implemented a comprehensive tobacco control program banning smoking in public places, banning advertising, and introducing graphic health warnings. The higher tobacco tax took effect in early 2010, allowing sufficient time for subsequent changes in prices and smoking to be observed by the time of the 2012 GATS. This report uses data from GATS Turkey to examine how cigarette prices changed after the 2010 tax increase, describe the temporally associated changes in smoking prevalence, and learn whether this smoking prevalence changed more in some demographic groups than others. From 2008 to 2012, the average price paid for cigarettes increased by 42.1%, cigarettes became less affordable, and smoking prevalence decreased by 14.6%. The largest reduction in smoking was observed among persons with lower socioeconomic status (SES), highlighting the potential role of tax policy in reducing health disparities across socioeconomic groups.

CDC Grand Rounds: global tobacco control

During the 20th century, use of tobacco products contributed to the deaths of 100 million persons worldwide. In 2011, approximately 6 million additional deaths were linked to tobacco use, the world's leading underlying cause of death, responsible for more deaths each year than human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), tuberculosis, and malaria combined. One third to one half of lifetime users die from tobacco products, and smokers die an average of 14 years earlier than nonsmokers. Manufactured cigarettes account for 96% of all tobacco sales worldwide. From 1880 to 2009, annual global consumption of cigarettes increased from an estimated 10 billion cigarettes to approximately 5.9 trillion cigarettes, with five countries accounting for 58% of the total consumption: China (38%), Russia (7%), the United States (5%), Indonesia (4%), and Japan (4%). Among the estimated 1 billion smokers worldwide, men outnumber women by four to one. In 14 countries, at least 50% of men smoke, whereas in more than half of these same countries, fewer than 10% of women smoke. If current trends persist, an estimated 500 million persons alive today will die from use of tobacco products. By 2030, tobacco use will result in the deaths of approximately 8 million persons worldwide each year. Yet, every death from tobacco products is preventable.

Profile of dual tobacco users in India: an analysis from Global Adult Tobacco Survey, 2009-10

INTRODUCTION

Individuals who use both smoked and smokeless tobacco products (dual tobacco users) form a special group about which little is known. This group is especially relevant to India, where smokeless tobacco use is very common. The aim of this study was to characterise the profile of dual users, study their pattern of initiation to the second product, their attitudes toward quittingas well as their cessation profile.

METHODS AND MATERIALS

The GATS dataset for India was analyzed using SPSS; .

RESULTS

In India, dual tobacco users (42.3 million; 5.3% of all adults; 15.4% of all tobacco users) have a profile similar to that of smokers. Some 52.6% of dual users started both practices within 2 years. The most prevalent product combination was bidi-khaini (1.79%) followed by bidi-gutka (1.50%), cigarette-khaini (1.28%), and cigarette-gutka (1.22%). Among daily users, the correlation between the daily frequencies of the use of each product was very high for most product combinations. While 36.7% of dual users were interested in quitting, only 5.0% of dual users could do so. The prevalence of ex-dual users was 0.4%.

CONCLUSION

Dual users constitute a large, high-risk group that requires special attention.

Predictors of tobacco smoking and smokeless tobacco use among adults in Bangladesh

INTRODUCTION

To examine predictors of current tobacco smoking and smokeless tobacco use among the adult population in Bangladesh.

MATERIALS AND METHODS

We used data from the 2009 Global Adult Tobacco Survey (GATS) in Bangladesh consisting of 9,629 adults aged ≥15 years. Differences in and predictors of prevalence for both smoking and smokeless tobacco use were analyzed using selected socioeconomic and demographic characteristics that included gender, age, place of residence, education, occupation, and an index of wealth.

RESULTS

The prevalence of smoking is high among males (44.7%, 95% confidence interval [CI]: 42.5-47.0) as compared to females (1.5%, 95% CI: 1.1-2.1), whereas the prevalence of smokeless tobacco is almost similar among both males (26.4%, 95% CI: 24.2-28.6) and females (27.9%, 95% CI: 25.9-30.0). Correlates of current smoking are male gender (odds ratio [OR] = 41.46, CI = 23.8-73.4), and adults in older age (ORs range from 1.99 in 24-35 years age to 5.49 in 55-64 years age), less education (ORs range from 1.47 in less than secondary to 3.25 in no formal education), and lower socioeconomic status (ORs range from 1.56 in high wealth index to 2.48 in lowest wealth index. Predictors of smokeless tobacco use are older age (ORs range from 2.54in 24-35 years age to 12.31 in 55-64 years age), less education (ORs range from 1.44 in less than secondary to 2.70 in no formal education), and the low (OR = 1.34, CI = 1.0-1.7) or lowest (OR = 1.43, CI = 1.1-1.9) socioeconomic status.

CONCLUSION

Implementation of tobacco control strategies needs to bring special attention on disadvantaged group and cover all types of tobacco product as outlined in the WHO Framework Convention on Tobacco Control (FCTC) and WHO MPOWER to protect people's health and prevent premature death.

Tracking MPOWER in 14 countries: results from the Global Adult Tobacco Survey, 2008–2010

Background:

The World Health Organization (WHO) MPOWER is a technical package of six tobacco control measures that assist countries in meeting their obligations of the WHO Framework Convention Tobacco Control and are proven to reduce tobacco use. The Global Adult Tobacco Survey (GATS) systematically monitors adult tobacco use and tracks key tobacco control indicators.

Methods:

GATS is a nationally representative household survey of adults aged 15 and older, using a standard and consistent protocol across countries; it includes information on the six WHO MPOWER measures. GATS Phase I was conducted from 2008–2010 in 14 high-burden low- and middle-income countries. We selected one key indicator from each of the six MPOWER measures and compared results across 14 countries.

Results:

Current tobacco use prevalence rates ranged from 16.1% in Mexico to 43.3% in Bangladesh. We found that the highest rate of exposure to secondhand smoke in the workplace was in China (63.3%). We found the highest ‘smoking quit attempt’ rates in the past 12 months among cigarette smokers in Viet Nam (55.3%) and the lowest rate was in the Russian Federation (32.1%). In five of the 14 countries, more than one-half of current smokers in those 5 countries said they thought of quitting because of health warning labels on cigarette packages. The Philippines (74.3%) and the Russian Federation (68.0%) had the highest percentages of respondents noticing any cigarette advertising, promotion and sponsorship. Manufactured cigarette affordability ranged from 0.6% in Russia to 8.0% in India.

Conclusions

Monitoring tobacco use and tobacco control policy achievements is crucial to managing and implementing measures to reverse the epidemic. GATS provides internationally-comparable data that systematically monitors and tracks the progress of the other five MPOWER measures.

Methodology of the Global Adult Tobacco Survey — 2008–2010

In 2008, the Centers for Disease Control and Prevention (CDC) and the World Health Organization developed the Global Adult Tobacco Survey (GATS), an instrument to monitor global tobacco use and measure indicators of tobacco control. GATS, a nationally representative household survey of persons aged 15 years or older, was conducted for the first time during 2008–2010 in 14 low- and middle-income countries. In each country, GATS used a standard core questionnaire, sample design, and procedures for data collection and management and, as needed, added country-specific questions that were reviewed and approved by international experts. The core questionnaire included questions about various characteristics of the respondents, their tobacco use (smoking and smokeless), and a wide range of tobacco-related topics (cessation; secondhand smoke; economics; media; and knowledge, attitudes, and perceptions). In each country, a multistage cluster sample design was used, with households selected proportionate to the size of the population. Households were chosen randomly within a primary or secondary sampling unit, and one respondent was selected at random from each household to participate in the survey. Interviewers administered the survey in the country’s local language(s) using handheld electronic data collection devices. Interviews were conducted privately, and same-sex interviewers were used in countries where mixed-sex interviews would be culturally inappropriate. All 14 countries completed the survey during 2008–2010. In each country, the ministry of health was the lead coordinating agency for GATS, and the survey was implemented by national statistical organizations or surveillance institutes. This article describes the background and rationale for GATS and includes a comprehensive description of the survey methods and protocol.

Prevalence of tobacco use among adults in Egypt, 2009

INTRODUCTION

We assessed the differences in overall use of tobacco and in the use of various tobacco products, by sex and by frequency of use across various demographic groups.

METHODS

We used data from the Global Adult Tobacco Survey (GATS), conducted in 2009 in Egypt. The data consist of answers to GATS by 20,924 respondents from a nationally representative, multistage probability sample of adults aged 15 years or older from all regions of Egypt. Current tobacco use was defined as current smoking or use of smokeless tobacco products, either daily or occasionally. We analyzed the differences in current cigarette, shisha, and smokeless tobacco use by sex and frequency of use (daily or occasional); and by demographic characteristics that included age, region, education level and employment status.

RESULTS

Overall, 19.7% of the Egyptian population currently use some form of tobacco. Men (38.1% [95% confidence interval (CI) 36.8-39.4]) are much more likely than women (0.6% [95% CI 0.4-0.9]) to use tobacco. Almost 96% of men who use tobacco, do so daily. Men are more likely to use manufactured cigarettes (31.8% [95% CI 30.6-33.1]) than shisha (6.2% [95% CI 5.6-6.9]) or smokeless tobacco (4.1% [95% CI 3.4-4.8]). Few women use tobacco (cigarettes (0.2%), shisha (0.3%) and smokeless tobacco (0.3%)); however, all women who currently smoke shisha, do so daily. Lower educational status, being between ages 25-64 and being employed predicted a higher use of tobacco.

CONCLUSION

Egypt has implemented several initiatives to reduce tobacco use. The World Health Organization (WHO) MPOWER technical package, which aims to reverse the tobacco epidemic, is implemented at various levels throughout the country. Our findings show that there is significant variation in the prevalence of tobacco use and types of tobacco used by adult men and women in Egypt. GATS data can be used to better understand comparative patterns of tobacco use by adults, which in turn can be used to develop interventions.

Exposure to secondhand smoke among adults – Philippines, 2009

Introduction:

We assessed the differences in exposure to secondhand smoke (SHS) among adults at home, in indoor workplaces, and in various public places in the Philippines across various socio-demographic groups.

Methods:

Data from the Global Adult Tobacco Survey conducted in 2009 in the Philippines were used. The data consist of survey answers from 9705 respondents from a nationally representative, multistage probability sample of adults aged 15 years or older. We considered that respondents were exposed to SHS if during the previous 30 days they reported that they lived in a home, worked in a building, or visited a public place where people smoked. The public places included in our analysis were indoor workplaces, public transportation vehicles, restaurants, government buildings or offices, and healthcare facilities. The differences in various socioeconomic and demographic groups’ exposure to SHS in these places were also examined.

Results:

Of respondents who reported working indoors, 36.8% were exposed to SHS. Men (43.3% [95% CI 39.7–46.9]) were more likely than women (28.8% [95% CI 25.4–32.4]) to be exposed to SHS ( p < 0.001). Of those working in sites where smoking was not allowed, 13.9% were exposed to SHS, whereas 66.5% were exposed where smoking is allowed in some enclosed areas, and 90.7% were exposed where smoking is allowed everywhere. During the 30 days preceding the survey, more than 50% of those who took public transportation were exposed to SHS; exposure for those who visited public buildings was 33.6% in restaurants, 25.5% in government buildings or offices, and 7.6% in healthcare facilities.

Conclusion:

Despite a national law passed and several local government ordinances that have promulgated smoke-free workplaces, schools, government offices, and healthcare facilities, our findings show that a large proportion of adults were exposed to SHS at work and in public places, which offers opportunities to strengthen and improve enforcement of the smoke-free initiatives and ordinances in the Philippines.

Cross-country comparison of waterpipe use: nationally representative data from 13 low and middle-income countries from the Global Adult Tobacco Survey (GATS)

OBJECTIVE

Evidence shows that smoking tobacco using a waterpipe is significantly associated with diseases. Despite this, waterpipe use seems to be increasing worldwide, though nationally representative data are not widely available. The Global Adult Tobacco Survey (GATS) provides an opportunity to measure various indicators of waterpipe use from nationally representative surveys.

METHODS

Data were obtained for adults 15 years of age or older from 13 countries (Bangladesh, Brazil, China, Egypt, India, Mexico, Philippines, Russia, Thailand, Turkey, Ukraine, Uruguay and Vietnam) who completed GATS from 2008-2010. The GATS questionnaire collected data on current waterpipe use, including daily/less than daily prevalence and number of sessions per day/week. An optional waterpipe module measured former use, age of initiation, and level of consumption during a session.

RESULTS

GATS was successful in producing nationally representative data on waterpipe use from 13 countries, many of which for the first time. The prevalence of waterpipe use among men was highest in Vietnam (13.0%) and Egypt (6.2%); among women, waterpipe use was highest in Russia (3.2%) and Ukraine (1.1%). While over 90% of adults in Ukraine thought smoking tobacco causes serious illness, only 31.4% thought smoking tobacco using a waterpipe causes serious illness.

CONCLUSIONS

GATS data provide the ability to analyse waterpipe use within a country and across countries. Monitoring of waterpipe use at a national level will better enable countries to target tobacco control interventions such as education campaigns about the negative health effects of waterpipe use.

Current manufactured cigarette smoking and roll-your-own cigarette smoking in Thailand: findings from the 2009 Global Adult Tobacco Survey

BACKGROUND

Current smoking prevalence in Thailand decreased from 1991 to 2004 and since that time the prevalence has remained flat. It has been suggested that one of the reasons that the prevalence of current smoking in Thailand has stopped decreasing is due to the use of RYO cigarettes. The aim of this study was to examine characteristics of users of manufactured and RYO cigarettes and dual users in Thailand, in order to determine whether there are differences in the characteristics of users of the different products.

METHODS

The 2009 Global Adult Tobacco Survey (GATS Thailand) provides detailed information on current smoking patterns. GATS Thailand used a nationally and regionally representative probability sample of 20,566 adults (ages 15 years and above) who were chosen through stratified three-stage cluster sampling and then interviewed face-to-face.

RESULTS

The prevalence of current smoking among Thai adults was 45.6% for men and 3.1% for women. In all, 18.4% of men and 1.0% of women were current users of manufactured cigarettes only, while 15.8% of men and 1.7% of women were current users of RYO cigarettes only. 11.2% of men and 0.1% of women used both RYO and manufactured cigarettes. Users of manufactured cigarettes were younger and users of RYO were older. RYO smokers were more likely to live in rural areas. Smokers of manufactured cigarettes appeared to be more knowledgeable about the health risks of tobacco use. However, the difference was confounded with age and education; when demographic variables were controlled, the knowledge differences no longer remained. Smokers of manufactured cigarettes were more likely than dual users and those who used only RYO to report that they were planning on quitting in the next month. Users of RYO only appeared to be more addicted than the other two groups as measured by time to first cigarette.

CONCLUSIONS

There appears to be a need for product targeted cessation and prevention efforts that are directed toward specific population subgroups in Thailand and include information on manufactured and RYO cigarettes.

Tobacco use, exposure to second-hand smoke, and cessation training among the third-year medical and dental students in selected Member States of South-East Asia region: a trend analysis on data from the Global Health Professions Student Survey, 2005-2011

BACKGROUND

The Medical and Dental Global Health Professions Student Surveys (GHPSS) are surveys based in schools that collect self-administered data from students on the prevalence of tobacco use, exposure to second-hand smoke, and tobacco cessation training, among the third-year medical and dental students.

MATERIALS AND METHODS

Two rounds of medical and dental GHPSS have been conducted in Bangladesh, India, Myanmar, Nepal, Sri Lanka, and Thailand, among the third-year medical and dental students, between 2005 and 2006 and 2009 and 2011.

RESULTS

The prevalence of any tobacco use among third-year male and female medical students did not change in Bangladesh, India, and Nepal between 2005 and 2006 and 2009 and 2011; however, it reduced significantly among females in Myanmar (3.3% in 2006 to 1.8% in 2009) and in Sri Lanka (2.5% in 2006 to 0.6% in 2011). The prevalence of any tobacco use among third-year male dental students did not change in Bangladesh, India, Nepal, and Thailand between 2005 and 2006 and 2009 and 2011; however, in Myanmar, the prevalence increased significantly (35.6% in 2006 to 49.5% in 2009). Among the third-year female students, a significant increase in prevalence was noticed in Bangladesh (4.0% in 2005 to 22.2% in 2009) and Thailand (0.7% in 2006 to 2.1% in 2011). It remained unchanged in the other three countries. Prevalence of exposure to second-hand smoke (SHS) both at home and in public places, among medical students, decreased significantly in Myanmar and Sri Lanka between 2006 and 2009 and in 2011. Among dental students, the prevalence of SHS exposure at home reduced significantly in Bangladesh, India, and Myanmar, and in public places in India. However, there was an increase of SHS exposure among dental students in Nepal, both at home and in public places, between 2005 and 2011. Medical students in Myanmar, Nepal, and Sri Lanka reported a declining trend in schools, with a smoking ban policy in place, between 2005 and 2006 and 2009 and 2011, while proportions of dental students reported that schools with a smoking ban policy have increased significantly in Bangladesh and Myanmar. Ever receiving cessation training increased significantly among medical students in Sri Lanka only, whereas, among dental students, it increased in India, Nepal, and Thailand.

CONCLUSION

Trends of tobacco use and exposure to SHS among medical and dental students in most countries of the South-East Asia Region had changed only relatively between the two rounds of GHPSS (2005-2006 and 2009-2011). No significant improvement was observed in the trend in schools with a policy banning smoking in school buildings and clinics. Almost all countries in the SEA Region that participated in GHPSS showed no significant change in ever having received formal training on tobacco cessation among medical and dental students.

Global school personnel survey among 5200 school personnel in India: comparison of the results for the years 2009 and 2006

BACKGROUND

The results of the Global School Personnel Survey (GSPS) conducted in India in 2009 are compared with 2006 GSPS to assess any change in 2009 on tobacco use and knowledge and attitudes to tobacco use, training and availability of tobacco control teaching material in schools and the existence of school tobacco control policies.

METHODS

GSPS is a cross sectional survey conducted twice (2006 and 2009) in entire India. A total of 180 schools were surveyed each time.

RESULTS

Of the participating school personnel, 2660 in 2006 and 2575 in 2009, about 95% were teachers and the balance administrators. In 2009, compared to 2006 the prevalence of current smoking of cigarettes (19.6% in 2006 and 10.3% in 2009) and bidis (21.5% in 2006 and 13.9% in 2009) was found to be significantly lower; the percentage of teachers receiving training on preventing youth tobacco use has significantly reduced (16.7% in 2006 and 10.1% in 2009); access of teachers to educational materials on tobacco use and how to prevent its use among youth had not increased (34.6% in 2006 and 37.8% in 2009); there was no change in policy prohibiting tobacco use among students and school personnel; however, ever use of any tobacco on school premises was significantly lower (15.6% in 2006 and 9.6% in 2009).

CONCLUSIONS

The prevalence of current smoking (cigarettes/bidis) among school personnel and use of any tobacco on school premises were significantly decreased in 2009 as compared to 2006. Necessary action should be planned to increase the number of teachers trained and the availability of teaching materials on preventing youth tobacco use in order to have effective prevention of tobacco use among students.

Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys

BACKGROUND

Despite the high global burden of diseases caused by tobacco, valid and comparable prevalence data for patterns of adult tobacco use and factors influencing use are absent for many low-income and middle-income countries. We assess these patterns through analysis of data from the Global Adult Tobacco Survey (GATS).

METHODS

Between Oct 1, 2008, and March 15, 2010, GATS used nationally representative household surveys with comparable methods to obtain relevant information from individuals aged 15 years or older in 14 low-income and middle-income countries (Bangladesh, Brazil, China, Egypt, India, Mexico, Philippines, Poland, Russia, Thailand, Turkey, Ukraine, Uruguay, and Vietnam). We compared weighted point estimates and 95% CIs of tobacco use between these 14 countries and with data from the 2008 UK General Lifestyle Survey and the 2006-07 US Tobacco Use Supplement to the Current Population Survey. All these surveys had cross-sectional study designs.

FINDINGS

In countries participating in GATS, 48·6% (95% CI 47·6-49·6) of men and 11·3% (10·7-12·0) of women were tobacco users. 40·7% of men (ranging from 21·6% in Brazil to 60·2% in Russia) and 5·0% of women (0·5% in Egypt to 24·4% in Poland) in GATS countries smoked a tobacco product. Manufactured cigarettes were favoured by most smokers (82%) overall, but smokeless tobacco and bidis were commonly used in India and Bangladesh. For individuals who had ever smoked daily, women aged 55-64 years at the time of the survey began smoking at an older age than did equivalently aged men in most GATS countries. However, those individuals who had ever smoked daily and were aged 25-34-years when surveyed started to do so at much the same age in both sexes. Quit ratios were very low (<20% overall) in China, India, Russia, Egypt, and Bangladesh.

INTERPRETATION

The first wave of GATS showed high rates of smoking in men, early initiation of smoking in women, and low quit ratios, reinforcing the view that efforts to prevent initiation and promote cessation of tobacco use are needed to reduce associated morbidity and mortality.

FUNDING

Bloomberg Philanthropies' Initiative to Reduce Tobacco Use, Bill and Melinda Gates Foundation, Brazilian and Indian Governments.