Susceptibility to smoking among South East Asian youth: a multilevel analysis.

OBJECTIVE: To estimate the extent to which susceptibility to smoking is associated with between-context differences (schools and classes) and to identify factors at school, class and individual levels that influence individual susceptibility to smoking among young never-smokers in South East Asia. METHODS: Cross-sectional data from the Global Youth Tobacco Survey conducted in Cambodia (2002), Laos (2003) and Vietnam (2003) are used to conduct multilevel analyses that account for the nesting of students in classes and classes in schools. The outcome variable is smoking susceptibility, defined as the absence of a firm decision not to smoke. Explanatory variables include school-level (current tobacco use prevalence in school, exposure to anti-smoking media messages and exposure to tobacco billboard advertising), class-level (classroom prevention) and individual-level influences (parents' and friends' smoking behaviour, knowledge of the harmful effects of and exposure to secondhand smoke at home, age, sex and pocket income). RESULTS: Multilevel analyses indicate that 4.5% and 4.2% of the variation in smoking susceptibility is associated with school and class differences, respectively. Students who have parents or friends who smoke, who are exposed to secondhand smoke at home and those who have access to pocket income are found to be more susceptible while greater knowledge of the harmful effects of secondhand smoke appears to diminish susceptibility to smoking. For girls only, billboard tobacco advertising increases the risk of susceptibility and classroom prevention decreases risk while for boys only, attendance at schools with higher prevalence of tobacco use increases risk of susceptibility and anti-smoking media messages decreases risk. CONCLUSIONS: This study highlights a number of modifiable factors associated with smoking susceptibility and identifies interactions between teen sex and several factors associated with the susceptibility to smoking. This finding provides support for the call to move beyond gender-blind tobacco control policies.

Trends and affordability of cigarette prices: ample room for tax increases and related health gains.

BACKGROUND: Increasing the price of tobacco products is arguably the most effective method of curbing the prevalence and consumption of tobacco products. Price increases would reduce the global burden of disease brought about by tobacco consumption. OBJECTIVES: To compare cigarette price data from more than 80 countries using varying methods, examine trends in prices and affordability during the 1990s, and explore various policy implications pertaining to tobacco prices. DESIGN: March 2001 cigarette price data from the Economist Intelligence Unit are used to compare cigarette prices across countries. To facilitate comparison and to assess affordability, prices are presented in US dollars, purchasing power parity (PPP) units using the Big Mac index as an indicator of PPP and in terms of minutes of labour required to purchase a pack of cigarettes. Annual real percentage changes in cigarette prices between 1990 and 2000 and annual changes in the minutes of labour required to buy cigarettes between 1991 and 2000 are also calculated to examine trends. RESULTS: Cigarette prices tend to be higher in wealthier countries and in countries that have strong tobacco control programmes. On the other hand, minutes of labour required to purchase cigarettes vary vastly between countries. Trends between 1990 and 2000 in real prices and minutes of labour indicate, with some exceptions, that cigarettes have become more expensive in most developed countries but more affordable in many developing countries. However, in the UK, despite recent increases in price, cigarettes are still more affordable than they were in the 1960s. CONCLUSIONS: The results suggest that there is ample room to increase tobacco prices through taxation. In too many countries, cigarette prices have failed to keep up with increases in the general price level of goods and services, rendering them more affordable in 2000 than they were at the beginning of the decade. Opportunities to increase government revenue and improve health through reduced consumption brought about by higher prices have been overlooked in many countries.

Building the evidence base for global tobacco control.

The tobacco control movement needs a global information system permitting routine monitoring of the tobacco trade, tobacco farming, the tobacco industry, the prevalence of tobacco use, associated mortality, and national resources for combating tobacco. The Tobacco Control Country Profiles database, a data collection initiative led by the American Cancer Society in collaboration with WHO and the Centers for Disease Control and Prevention, represents the first step in the development of such a system. Baseline data on several indicators of tobacco use were obtained from 191 Member States of WHO, two Associate Members, Hong Kong Special Administrative Region of China (Hong Kong SAR), China (Province of Taiwan) and the West Bank and Gaza Strip. The methods used to compile the data are described in the present paper. Selected indicators from the database were analysed in order to demonstrate the potential utility and value of data derived from an information system devoted to tobacco control. The analyses covered gender-specific smoking prevalence by WHO Region, per capita cigarette consumption by Human Development Index (HDI) category, and average real annual percentage changes in cigarette prices between 1990 and 1999 for selected countries in each category. In 1998, men were almost four times more likely than women to be smokers. The prevalence of smoking among men was highest in the Western Pacific Region. The differential in gender-specific smoking prevalence was narrowest in the Region of the Americas and the European Region. It was wider in the South-East Asia Region and the Western Pacific Region. The lowest and highest per capita consumption of manufactured cigarettes occurred in the lowest and highest HDI categories respectively. In the medium HDI category, China's growing cigarette consumption after 1975 had a major bearing on the rise in per capita consumption. Cigarette price trends suggest that there is considerable scope for increasing taxes on tobacco products, particularly in low or medium HDI countries. The implications of the findings for future tobacco control efforts are discussed, as are issues surrounding the quality of available data, priorities for future data collection and the need to maintain and improve the information system in order to support such efforts.

Global trade and health: key linkages and future challenges.

Globalization of trade, marketing and investment has important implications for public health, both negative and positive. This article considers the implications of the single package of World Trade Organization (WTO) agreements for public health research and policy, focusing on three themes: commodities, intellectual property rights, and health services. The main aims of the analysis are as follows: to identify how trade issues are associated with the transnationalization of health risks and possible benefits; to identify key areas of research; and to suggest policy-relevant advice and interventions on trade and health issues. The next wave of international trade law will need to take more account of global public health issues. However, to become more engaged in global trade debates, the public health community must gain an understanding of the health effects of global trade agreements. It must also ensure that its own facts are correct, so that public health is not blindly used for political ends, such as justifying unwarranted economic protectionism. "Healthy trade" policies, based on firm empirical evidence and designed to improve health status, are an important step towards reaching a more sustainable form of trade liberalization.