Case for investment in tobacco cessation: a population-based analysis in low- and middle-income countries.

This study aimed to estimate the return on investments of three population-level tobacco cessation strategies and three pharmacological interventions. The analysis included 124 low- and middle-income countries, and assumed a 10-year investment period (2021-2030). The results indicate that all six cessation programmes could help about 152 million tobacco users quit and save 2.7 million lives during 2021-2030. If quitters were followed until 65 years of age, 16 million lives could be saved from quitting. The combined investment cost was estimated at 1.68 United States dollars (US$) per capita a year, or US$ 115 billion over the period 2021-2030, with Caribbean countries showing the lowest investment cost at US$ 0.50 per capita a year. Return on investments was estimated at 0.79 (at the end of 2030) and 7.50 if benefits were assessed by the time quitters reach the age of 65 years. Disaggregated results by country income level and region also showed a return on investments less than 1.0 in the short term and greater than 1.0 in the medium-to-long term. In all countries, population-level interventions were less expensive and yielded a return on investments greater than 1.0 in the short and long term, with investment cost estimated at US$ 0.21 per capita a year, or US$ 14.3 billion over 2021-2030. Pharmacological interventions were more expensive and became cost beneficial over a longer time. These results are likely conservative and provide support for a phased approach implementing population-level strategies first, where most countries would reach break-even before 2030.

Este estudio tenía como objetivo estimar el rendimiento de la inversión de tres estrategias para el abandono del tabaco dirigidas a la población y de tres intervenciones farmacológicas. El análisis incluyó a 124 países de ingreso bajo y mediano y consideró que el período de inversión era de 10 años (2021-2030). Los resultados muestran que los seis programas sobre el abandono del tabaco podrían ayudar a unos 152 millones de personas a dejar el tabaco y salvar 2,7 millones de vidas en el período 2021-2030. Si se siguiera a las personas que dejan el tabaco hasta que cumpliesen 65 años, el número de vidas que se podrían salvar sería de 16 millones. Se estimó que el costo combinado de la inversión era de 1,68 dólares estadounidenses (US$) per cápita al año, o US$ 115 billones durante el período 2021-2030, y que el costo de inversión más bajo se encontraba en los países del Caribe (US$ 0,50 per cápita al año). Se estimó que el rendimiento de la inversión era de 0,79 (a finales de 2030) y de 7,50 si se tenían en cuenta los beneficios que obtienen las personas que dejan el tabaco hasta que alcanzan los 65 años. Los resultados desglosados por nivel de ingresos de los países y región también mostraron que el rendimiento de la inversión era inferior a 1,0 a corto plazo y superior a 1,0 de mediano a largo plazo. En todos los países, las intervenciones dirigidas a la población fueron menos costosas y produjeron un rendimiento de la inversión superior a 1,0 a corto y largo plazo, con un costo de las inversiones estimado en US$ 0,21 per cápita al año, o US$ 14,3 billones durante el período 2021-2030. Las intervenciones farmacológicas fueron más costosas y solo fueron generaron beneficios en función de los costos a más largo plazo. Probablemente son unos resultados prudentes, pero sirven de base para adoptar un enfoque gradual en la aplicación de estrategias dirigidas a la población primero donde la mayoría de los países alcanzarían el punto de equilibrio antes del 2030.

Este estudo teve como objetivo estimar o retorno dos investimentos de três estratégias de cessação do tabagismo no nível populacional e de três intervenções farmacológicas. A análise incluiu 124 países de baixa e média renda e presumiu um período de investimento de 10 anos (2021-2030). Os resultados indicam que todos os seis programas de cessação poderiam ajudar cerca de 152 milhões de usuários de tabaco a parar de fumar e salvar 2,7 milhões de vidas entre 2021 e 2030. Se houvesse acompanhamento até os 65 anos de idade daqueles que parassem de fumar, 16 milhões de vidas poderiam ser salvas. O custo de investimento combinado foi estimado em 1,68 dólares americanos (US$) per capita por ano, ou US$ 115 bilhões no período 2021-2030, com os países do Caribe apresentando o menor custo de investimento, a US$ 0,50 per capita por ano. O retorno dos investimentos foi estimado em 0,79 (no fim de 2030) e 7,50 se os benefícios fossem avaliados até o momento em que aqueles que pararam de fumar chegassem aos 65 anos de idade. Os resultados desagregados por nível de renda nacional e por região também mostraram um retorno dos investimentos inferior a 1,0 no curto prazo e superior a 1,0 no médio e longo prazos. Em todos os países, as intervenções no nível populacional foram menos caras e renderam um retorno dos investimentos superior a 1,0 no curto e longo prazos, com um custo de investimento estimado em US$ 0,21 per capita por ano, ou US$ 14,3 bilhões entre 2021 e 2030. As intervenções farmacológicas foram mais caras e tiveram um bom custo-benefício durante um período mais longo. Estes resultados são provavelmente conservadores e servem de apoio para uma abordagem em fases que implemente primeiramente estratégias no nível populacional, onde a maioria dos países atingiria o ponto de equilíbrio antes de 2030.

Case for investment in tobacco cessation: a population based analysis in low- and middle-income countries

[ABSTRACT]. This study aimed to estimate the return on investments of three population-level tobacco cessation strategies and three pharmacological interventions. The analysis included 124 low- and middle-income countries, and assumed a 10-year investment period (2021–2030). The results indicate that all six cessation programmes could help about 152 million tobacco users quit and save 2.7 million lives during 2021–2030. If quitters were followed until 65 years of age, 16 million lives could be saved from quitting. The combined investment cost was estimated at 1.68 United States dollars (US$) per capita a year, or US$ 115 billion over the period 2021– 2030, with Caribbean countries showing the lowest investment cost at US$ 0.50 per capita a year. Return on investments was estimated at 0.79 (at the end of 2030) and 7.50 if benefits were assessed by the time quitters reach the age of 65 years. Disaggregated results by country income level and region also showed a return on investments less than 1.0 in the short term and greater than 1.0 in the medium-to-long term. In all countries, population-level interventions were less expensive and yielded a return on investments greater than 1.0 in the short and long term, with investment cost estimated at US$ 0.21 per capita a year, or US$ 14.3 billion over 2021–2030. Pharmacological interventions were more expensive and became cost beneficial over a longer time. These results are likely conservative and provide support for a phased approach implementing popula- tion-level strategies first, where most countries would reach break-even before 2030.

[RESUMEN]. Este estudio tenía como objetivo estimar el rendimiento de la inversión de tres estrategias para el abandono del tabaco dirigidas a la población y de tres intervenciones farmacológicas. El análisis incluyó a 124 países de ingreso bajo y mediano y consideró que el período de inversión era de 10 años (2021-2030). Los resul- tados muestran que los seis programas sobre el abandono del tabaco podrían ayudar a unos 152 millones de personas a dejar el tabaco y salvar 2,7 millones de vidas en el período 2021-2030. Si se siguiera a las personas que dejan el tabaco hasta que cumpliesen 65 años, el número de vidas que se podrían salvar sería de 16 millones. Se estimó que el costo combinado de la inversión era de 1,68 dólares estadounidenses (US$) per cápita al año, o US$ 115 billones durante el período 2021-2030, y que el costo de inversión más bajo se encontraba en los países del Caribe (US$ 0,50 per cápita al año). Se estimó que el rendimiento de la inversión era de 0,79 (a finales de 2030) y de 7,50 si se tenían en cuenta los beneficios que obtienen las personas que dejan el tabaco hasta que alcanzan los 65 años. Los resultados desglosados por nivel de ingresos de los países y región también mostraron que el rendimiento de la inversión era inferior a 1,0 a corto plazo y superior a 1,0 de mediano a largo plazo. En todos los países, las intervenciones dirigidas a la población fueron menos costosas y produjeron un rendimiento de la inversión superior a 1,0 a corto y largo plazo, con un costo de las inversiones estimado en US$ 0,21 per cápita al año, o US$ 14,3 billones durante el período 2021-2030. Las intervenciones farmacológicas fueron más costosas y solo fueron generaron beneficios en función de los costos a más largo plazo. Probablemente son unos resultados prudentes, pero sirven de base para adoptar un enfoque gradual en la aplicación de estrategias dirigidas a la población primero donde la mayoría de los países alcanzarían el punto de equilibrio antes del 2030.

[RESUMO]. Este estudo teve como objetivo estimar o retorno dos investimentos de três estratégias de cessação do taba- gismo no nível populacional e de três intervenções farmacológicas. A análise incluiu 124 países de baixa e média renda e presumiu um período de investimento de 10 anos (2021-2030). Os resultados indicam que todos os seis programas de cessação poderiam ajudar cerca de 152 milhões de usuários de tabaco a parar de fumar e salvar 2,7 milhões de vidas entre 2021 e 2030. Se houvesse acompanhamento até os 65 anos de idade daqueles que parassem de fumar, 16 milhões de vidas poderiam ser salvas. O custo de investimento combinado foi estimado em 1,68 dólares americanos (US$) per capita por ano, ou US$ 115 bilhões no período 2021-2030, com os países do Caribe apresentando o menor custo de investimento, a US$ 0,50 per capita por ano. O retorno dos investimentos foi estimado em 0,79 (no fim de 2030) e 7,50 se os benefícios fossem avali- ados até o momento em que aqueles que pararam de fumar chegassem aos 65 anos de idade. Os resultados desagregados por nível de renda nacional e por região também mostraram um retorno dos investimentos inferior a 1,0 no curto prazo e superior a 1,0 no médio e longo prazos. Em todos os países, as intervenções no nível populacional foram menos caras e renderam um retorno dos investimentos superior a 1,0 no curto e longo prazos, com um custo de investimento estimado em US$ 0,21 per capita por ano, ou US$ 14,3 bilhões entre 2021 e 2030. As intervenções farmacológicas foram mais caras e tiveram um bom custo-benefício durante um período mais longo. Estes resultados são provavelmente conservadores e servem de apoio para uma abordagem em fases que implemente primeiramente estratégias no nível populacional, onde a maioria dos países atingiria o ponto de equilíbrio antes de 2030.

Case for investment in tobacco cessation: a population-based analysis in low- and middle-income countries / Argumentos a favor de la inversión en iniciativas para el abandono del tabaco: un análisis basado en la población en países de ingreso bajo y mediano / Análise de viabilidade de investimento na cessação do tabagismo: um estudo populacional em países de baixa e média renda

ABSTRACT This study aimed to estimate the return on investments of three population-level tobacco cessation strategies and three pharmacological interventions. The analysis included 124 low- and middle-income countries, and assumed a 10-year investment period (2021-2030). The results indicate that all six cessation programmes could help about 152 million tobacco users quit and save 2.7 million lives during 2021-2030. If quitters were followed until 65 years of age, 16 million lives could be saved from quitting. The combined investment cost was estimated at 1.68 United States dollars (US$) per capita a year, or US$ 115 billion over the period 2021-2030, with Caribbean countries showing the lowest investment cost at US$ 0.50 per capita a year. Return on investments was estimated at 0.79 (at the end of 2030) and 7.50 if benefits were assessed by the time quitters reach the age of 65 years. Disaggregated results by country income level and region also showed a return on investments less than 1.0 in the short term and greater than 1.0 in the medium-to-long term. In all countries, population-level interventions were less expensive and yielded a return on investments greater than 1.0 in the short and long term, with investment cost estimated at US$ 0.21 per capita a year, or US$ 14.3 billion over 2021-2030. Pharmacological interventions were more expensive and became cost beneficial over a longer time. These results are likely conservative and provide support for a phased approach implementing population-level strategies first, where most countries would reach break-even before 2030.

RESUMEN Este estudio tenía como objetivo estimar el rendimiento de la inversión de tres estrategias para el abandono del tabaco dirigidas a la población y de tres intervenciones farmacológicas. El análisis incluyó a 124 países de ingreso bajo y mediano y consideró que el período de inversión era de 10 años (2021-2030). Los resultados muestran que los seis programas sobre el abandono del tabaco podrían ayudar a unos 152 millones de personas a dejar el tabaco y salvar 2,7 millones de vidas en el período 2021-2030. Si se siguiera a las personas que dejan el tabaco hasta que cumpliesen 65 años, el número de vidas que se podrían salvar sería de 16 millones. Se estimó que el costo combinado de la inversión era de 1,68 dólares estadounidenses (US$) per cápita al año, o US$ 115 billones durante el período 2021-2030, y que el costo de inversión más bajo se encontraba en los países del Caribe (US$ 0,50 per cápita al año). Se estimó que el rendimiento de la inversión era de 0,79 (a finales de 2030) y de 7,50 si se tenían en cuenta los beneficios que obtienen las personas que dejan el tabaco hasta que alcanzan los 65 años. Los resultados desglosados por nivel de ingresos de los países y región también mostraron que el rendimiento de la inversión era inferior a 1,0 a corto plazo y superior a 1,0 de mediano a largo plazo. En todos los países, las intervenciones dirigidas a la población fueron menos costosas y produjeron un rendimiento de la inversión superior a 1,0 a corto y largo plazo, con un costo de las inversiones estimado en US$ 0,21 per cápita al año, o US$ 14,3 billones durante el período 2021-2030. Las intervenciones farmacológicas fueron más costosas y solo fueron generaron beneficios en función de los costos a más largo plazo. Probablemente son unos resultados prudentes, pero sirven de base para adoptar un enfoque gradual en la aplicación de estrategias dirigidas a la población primero donde la mayoría de los países alcanzarían el punto de equilibrio antes del 2030.

RESUMO Este estudo teve como objetivo estimar o retorno dos investimentos de três estratégias de cessação do tabagismo no nível populacional e de três intervenções farmacológicas. A análise incluiu 124 países de baixa e média renda e presumiu um período de investimento de 10 anos (2021-2030). Os resultados indicam que todos os seis programas de cessação poderiam ajudar cerca de 152 milhões de usuários de tabaco a parar de fumar e salvar 2,7 milhões de vidas entre 2021 e 2030. Se houvesse acompanhamento até os 65 anos de idade daqueles que parassem de fumar, 16 milhões de vidas poderiam ser salvas. O custo de investimento combinado foi estimado em 1,68 dólares americanos (US$) per capita por ano, ou US$ 115 bilhões no período 2021-2030, com os países do Caribe apresentando o menor custo de investimento, a US$ 0,50 per capita por ano. O retorno dos investimentos foi estimado em 0,79 (no fim de 2030) e 7,50 se os benefícios fossem avaliados até o momento em que aqueles que pararam de fumar chegassem aos 65 anos de idade. Os resultados desagregados por nível de renda nacional e por região também mostraram um retorno dos investimentos inferior a 1,0 no curto prazo e superior a 1,0 no médio e longo prazos. Em todos os países, as intervenções no nível populacional foram menos caras e renderam um retorno dos investimentos superior a 1,0 no curto e longo prazos, com um custo de investimento estimado em US$ 0,21 per capita por ano, ou US$ 14,3 bilhões entre 2021 e 2030. As intervenções farmacológicas foram mais caras e tiveram um bom custo-benefício durante um período mais longo. Estes resultados são provavelmente conservadores e servem de apoio para uma abordagem em fases que implemente primeiramente estratégias no nível populacional, onde a maioria dos países atingiria o ponto de equilíbrio antes de 2030.

Development of the "National Asbestos Profile" to Eliminate Asbestos-Related Diseases in 195 Countries.

Worldwide, 230,000+ people die annually from asbestos-related diseases (ARDs). The World Health Organization (WHO) recommends that countries develop a National Asbestos Profile (NAP) to eliminate ARDs. For 195 countries, we assessed the global status of NAPs (A: bona fide NAP, B: proxy NAP, C: relevant published information, D: no relevant information) by national income (HI: high, UMI: upper-middle, LMI: lower-middle, LI: low), asbestos bans (banned, no-ban) and public data availability. Fourteen (7% of 195) countries were category A (having a bona fide NAP), while 98, 51 and 32 countries were categories B, C and D, respectively. Of the 14 category-A countries, 8, 3 and 3 were LMI, UMI and HI, respectively. Development of a bona fide NAP showed no gradient by national income. The proportions of countries having a bona fide NAP were similar between asbestos-banned and no-ban countries. Public databases useful for developing NAPs contained data for most countries. Irrespective of the status of national income or asbestos ban, most countries have not developed a NAP despite having the potential. The global status of NAP is suboptimal. Country-level data on asbestos and ARDs in public databases can be better utilized to develop NAPs for globally eliminating ARDs.

Global Asbestos Disaster.

Introduction: Asbestos has been used for thousands of years but only at a large industrial scale for about 100⁻150 years. The first identified disease was asbestosis, a type of incurable pneumoconiosis caused by asbestos dust and fibres. The latest estimate of global number of asbestosis deaths from the Global Burden of Disease estimate 2016 is 3495. Asbestos-caused cancer was identified in the late 1930's but despite today's overwhelming evidence of the strong carcinogenicity of all asbestos types, including chrysotile, it is still widely used globally. Various estimates have been made over time including those of World Health Organization and International Labour Organization: 107,000⁻112,000 deaths. Present estimates are much higher. Objective: This article summarizes the special edition of this Journal related to asbestos and key aspects of the past and present of the asbestos problem globally. The objective is to collect and provide the latest evidence of the magnitude of asbestos-related diseases and to provide the present best data for revitalizing the International Labor Organization/World Health Organization Joint Program on Asbestos-related Diseases. Methods: Documentation on asbestos-related diseases, their recognition, reporting, compensation and prevention efforts were examined, in particular from the regulatory and prevention point of view. Estimated global numbers of incidence and mortality of asbestos-related diseases were examined. Results: Asbestos causes an estimated 255,000 deaths (243,223⁻260,029) annually according to latest knowledge, of which work-related exposures are responsible for 233,000 deaths (222,322⁻242,802). In the European Union, United States of America and in other high income economies (World Health Organization regional classification) the direct costs for sickness, early retirement and death, including production losses, have been estimated to be very high; in the Western European countries and European Union, and equivalent of 0.70% of the Gross Domestic Product or 114 × 108 United States Dollars. Intangible costs could be much higher. When applying the Value of Statistical Life of 4 million EUR per cancer death used by the European Commission, we arrived at 410 × 108 United States Dollars loss related to occupational cancer and 340 × 108 related to asbestos exposure at work, while the human suffering and loss of life is impossible to quantify. The numbers and costs are increasing practically in every country and region in the world. Asbestos has been banned in 55 countries but is used widely today; some 2,030,000 tons consumed annually according to the latest available consumption data. Every 20 tons of asbestos produced and consumed kills a person somewhere in the world. Buying 1 kg of asbestos powder, e.g., in Asia, costs 0.38 United States Dollars, and 20 tons would cost in such retail market 7600 United States Dollars. Conclusions: Present efforts to eliminate this man-made problem, in fact an epidemiological disaster, and preventing exposures leading to it are insufficient in most countries in the world. Applying programs and policies, such as those for the elimination of all kind of asbestos use-that is banning of new asbestos use and tight control and management of existing structures containing asbestos-need revision and resources. The International Labor Organization/World Health Organization Joint Program for the Elimination of Asbestos-Related Diseases needs to be revitalized. Exposure limits do not protect properly against cancer but for asbestos removal and equivalent exposure elimination work, we propose a limit value of 1000 fibres/m³.

Defining a global research and policy agenda for betel quid and areca nut.

Betel quid and areca nut are known risk factors for many oral and oesophageal cancers, and their use is highly prevalent in the Asia-Pacific region. Additionally, betel quid and areca nut are associated with health effects on the cardiovascular, nervous, gastrointestinal, metabolic, respiratory, and reproductive systems. Unlike tobacco, for which the WHO Framework Convention on Tobacco Control provides evidence-based policies for reducing tobacco use, no global policy exists for the control of betel quid and areca nut use. Multidisciplinary research is needed to address this neglected global public health emergency and to mobilise efforts to control betel quid and areca nut use. In addition, future research is needed to advance our understanding of the basic biology, mechanisms, and epidemiology of betel quid and areca nut use, to advance possible prevention and cessation programmes for betel quid and areca nut users, and to design evidence-based screening and early diagnosis programmes to address the growing burden of cancers that are associated with use.

The use of tobacco tax revenues to fund the Guam Cancer Registry: A double win for cancer control.

Cancer registries that provide reliable data on cancer incidence, mortality and burden are essential to cancer control. However, establishing sustainable local funding mechanisms to support cancer registries remains a challenge in many countries. Guam, an unincorporated Territory of the United States of America in the Western Pacific, enacted a bill that raised tobacco taxes, and earmarked a percentage of tobacco tax revenues to support its Cancer Registry. This provided a reliable funding stream for the Registry, allowing for continued staffing and capacity building; at the same time, youth tobacco consumption decreased following the tax increase. Linking tobacco tax revenues to cancer registry support is a feasible strategy with a double benefit: higher tobacco prices from higher tobacco taxes reduce tobacco-related cancer risk while assuring the long-term viability of systematic cancer data collection and dissemination.

Building capacity for implementation of the framework convention for tobacco control in Vietnam: lessons for developing countries.

Effective implementation of the WHO international Framework Convention on Tobacco Control (FCTC) is the key to controlling the tobacco epidemic. Within countries, strong national tobacco control capacity is the primary determinant for successful implementation of the FCTC. This case study of tobacco control policy describes the experience of building national tobacco control capacity in Vietnam under the Reduce Smoking in Vietnam Partnership project within a national capacity-building framework. In the Vietnam experience, four components of tobacco control capacity emerged as especially important to achieve 'quality' outputs and measurable outcomes at the implementation level: (i) organizational structure/infrastructure; (ii) leadership and expertise; (iii) partnerships and networks and (iv) data and evidence from research. The experience gained in this project helps in adapting our tobacco control capacity-building model, and the lessons that emerged from this country case study can provide guidance to global funders, tobacco control technical assistance providers and nations as governments endeavor to meet their commitment to the FCTC.

Building tobacco cessation capacity in the U.S.-affiliated Pacific Islands.

Tobacco control stakeholders in priority populations are searching for culturally appropriate cessation training models to strengthen cessation capacity and infrastructure. We adapted the University of Arizona model for Brief Tobacco Cessation Interventions training for Pacific Islanders and pilot-tested it in four Pacific Islands-Palau, the Federated States of Micronesia, the Northern Mariana Islands and the Marshall Islands. All participants completed a posttraining knowledge assessment exam, pre- and posttraining confidence assessments, and a quality improvement evaluation. Of 70 participants, 65 (93%) completed the training. Forty-one (63%) passed the posttraining knowledge assessment exam at the first attempt; an additional 9 (14%) successfully passed on their second attempt, for a total pass rate of 77%. The pre- and posttraining confidence surveys demonstrated a statistically significant increase in confidence across all competency areas for delivering brief advice. The quality improvement survey revealed high acceptance and approval for the content and delivery of the locally adapted training model. As Pacific Island communities enact tobacco control policies, cessation demand is growing. The Guam cessation training model used culturally relevant data, materials, and training approaches and appeared effective in four different Pacific island countries. This underscores the importance of culturally competent adaptation of cessation training for priority populations such as Pacific Islanders.

Eliminating tobacco-related disparities among Pacific Islanders through leadership and capacity building: promising practices and lessons learned.

Tobacco remains a major risk factor for premature death and ill health among Pacific Islanders, and tobacco-related disparities persist. Eliminating these disparities requires a comprehensive approach to transform community norms about tobacco use through policy change, as contained in the World Health Organization international Framework Convention on Tobacco Control. Three of the six U.S.-affiliated Pacific Islands-the Federated States of Micronesia, Palau, and the Marshall Islands-are Parties to the Framework; the remaining three territories-American Samoa, the Commonwealth of the Northern Mariana Islands, and Guam-are excluded from the treaty by virtue of U.S. nonratification. Capacity building and leadership development are essential in achieving policy change and health equity within Pacific Islander communities. We describe promising practices from American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Guam, and Palau and highlight some of the key lessons learned in supporting and sustaining the reduction in tobacco use among Pacific Islanders as the first step toward eliminating tobacco-related disparities in these populations.

A baseline profile of asbestos in the US-affiliated Pacific Islands.

Asbestos is a recognized occupational and environmental hazard in the Asia-Pacific region, yet information regarding asbestos consumption, exposure, and asbestos-related diseases in the US-affiliated Pacific Islands (USAPIs) is scarce, and the situation regarding asbestos in these islands, particularly with regard to disease burden, surveillance, and health care capacity, is not well understood. Searching through scientific and "gray" literature and interviews with local cancer registry personnel and health professionals yielded no published data, only sufficient, indirect evidence of past and ongoing asbestos exposure, documented cases of mesothelioma and asbestosis, and minimal capacity for preventing and recognizing asbestos-related illnesses. Capacity and resource limitations within the USAPIs can impede regional progress in asbestos prevention and highlight the need for an integrated regional approach to address these data and capacity gaps. A regional mechanism to share expertise and resources and facilitate technical assistance to the USAPIs is urgently needed.

Public policy action and CCC implementation: benefits and hurdles.

Policy change continues to be an increasingly effective means of advancing the agenda of comprehensive cancer control. Efforts have moved progressively from describing how public policy can enhance the comprehensive cancer control agenda to implementation of public policy best practices at both the state and federal levels. The current political and economic contexts bring additional challenges and opportunities to the efforts surrounding comprehensive cancer control and policy. The purpose of this paper is to highlight recent policy successes, to illustrate the importance of policy as a means of advancing the comprehensive cancer control agenda, and to discuss continued policy action as we move forward in a time of healthcare reform and continuing economic uncertainty.

Getting the patients' perspective: a survey of diabetes services on Guam.

The prevention and control of diabetes is a major public health priority for the US Territory of Guam. As part of a strategic planning process, a survey of diabetes patients was conducted to determine patients' perceptions of the availability and adequacy of preventive and clinical services to control diabetes. A total of 125 survey questionnaires were distributed to diabetes patients attending either one of the Guam Department of Public Health and Social Services Community Health Centers or a private Internal Medicine/Endocrinology clinical practice of the only endocrinologist on the island. All 125 questionnaires were returned. Respondents were highly aware of the duration of their diabetes, and almost 75% have had the opportunity to discuss the chronic nature of the illness and the importance of key lifestyle changes to help prevent or retard the progression of the disease. However, almost 40% of patients were not aware of the type of diabetes they had, and one in five have not received diabetes self-management education from their health care providers. Key interventions, such as nutritional counseling, brief tobacco cessation interventions, regular eye and foot examinations and immunization services were not being provided to 30% to 60% of patients, despite clinical practice guidelines that recommend these interventions for all diabetics. While over half of respondents were generally satisfied with the quality of preventive and routine medical care that they receive from their service providers, they identified the need for better quality diabetes self-management education, preventive services, enhanced access to specialists and specialized care, especially for diabetes-related complications, and better financial support to assist them in meeting the costs of chronic care and medications. The feedback from these respondents should provide guidance regarding service gaps and needs as the Department of Public Health and Social Services and its community partners collaboratively develop a strategic plan to better address diabetes prevention and control on Guam. The information should also serve to direct quality improvement efforts to enhance existing diabetes services on the island.

The prevention and control of HIV/AIDS, TB and Vector-borne diseases in informal settlements: challenges, opportunities and insights.

Today's urban settings are redefining the field of public health. The complex dynamics of cities, with their concentration of the poorest and most vulnerable (even within the developed world) pose an urgent challenge to the health community. While retaining fidelity to the core principles of disease prevention and control, major adjustments are needed in the systems and approaches to effectively reach those with the greatest health risks (and the least resilience) within today's urban environment. This is particularly relevant to infectious disease prevention and control. Controlling and preventing HIV/AIDS, tuberculosis and vector-borne diseases like malaria are among the key global health priorities, particularly in poor urban settings. The challenge in slums and informal settlements is not in identifying which interventions work, but rather in ensuring that informal settlers: (1) are captured in health statistics that define disease epidemiology and (2) are provided opportunities equal to the rest of the population to access proven interventions. Growing international attention to the plight of slum dwellers and informal settlers, embodied by Goal 7 Target 11 of the Millennium Development Goals, and the considerable resources being mobilized by the Global Fund to fight AIDS, TB and malaria, among others, provide an unprecedented potential opportunity for countries to seriously address the structural and intermediate determinants of poor health in these settings. Viewed within the framework of the "social determinants of disease" model, preventing and controlling HIV/AIDS, TB and vector-borne diseases requires broad and integrated interventions that address the underlying causes of inequity that result in poorer health and worse health outcomes for the urban poor. We examine insights into effective approaches to disease control and prevention within poor urban settings under a comprehensive social development agenda.

Community leader support for tobacco control activities & policies on Guam.

OBJECTIVES: Guam has the highest smoking rate in the United States. This study examined Guam community leaders' attitudes toward cigarette smoking and their interest in changing local tobacco control policies. DESIGN: Cross-sectional survey. SETTING: Guam community leaders completed surveys while attending local professional conferences or meetings. PARTICIPANTS: Seventy-three percent of the respondents were female; the mean age was 46 years (SD = 15), and over 86% were from ethnic minority groups (47% Filipino, 28% Chamorro, 10% Asian, 2% other Pacific Island groups). About 30% reported being native Guamanian, and of those who immigrated to Guam had lived on Guam a mean of 17 years (SD = 11). OUTCOMES: Tobacco use was rated as a serious problem for Guam by 73% of the leaders surveyed, and a majority agreed that stricter tobacco control policies were needed on Guam. RESULTS: When asked to rate their preferences for tobacco control efforts on Guam, most (63%) preferred to focus on cessation efforts and 55% wanted to focus on smoke-free public places. CONCLUSIONS: This study provided critical insight about community leader support for stronger tobacco control measures on Guam, especially with respect to smoking cessation and smoke-free environments. Such a consensus of opinions could become a catalyst to promote community-wide tobacco control policies and programs. In addition, this study may provide a platform for future research on the structure and effectiveness of community leader support in a multicultural environment.

Hepatitis A outbreaks--methods of intervention in South-East Asian countries.

INTRODUCTION: In many Asian countries, improved hygiene standards and socio-economic conditions have led to a reduction in exposure to the hepatitis A virus (HAV) in childhood. However, the persistence of circulating HAV may lead to hepatitis A outbreaks, particularly in adolescents and adults. In other countries and specific areas, where socio-economic conditions have not improved as markedly, HAV endemicity remains medium-to-high. A systematic approach to outbreak control is therefore urgently needed. METHODS: The Steering Committee for Prevention and Control of Infectious Diseases reviewed reports on recent hepatitis A outbreaks in South-East Asian countries and determined that there is no systematic regional plan for the containment of such outbreaks. By contrast, on reviewing reports on outbreaks in several North American and European countries, it was found that the most important elements of successful outbreak control are a plan of action, rapid and widespread communication, public education and vaccination of household contacts to prevent secondary cases. RESULTS: This investigation proposes an outbreak control programme consisting of six key stages -- initiation, planning, set-up, implementation, vaccination of at-risk populations and evaluation. Outbreak control requires the formation of an outbreak management team, plus a task force to implement intervention and educate the public. The vaccination of family members and close contacts is a central element of the programme. CONCLUSION: This model programme for hepatitis A outbreak control provides a framework for action in countries and specific areas where the disease remains a problem.