Improving Information to Enable Effective Tobacco Control Intervention and Measure Progress Over Time: The Cambodia Country Experience.

Tobacco is a leading cause of noncommunicable diseases (NCDs) which kill about 41 million people each year. Of these, 15 million die prematurely between the ages of 30 and 69 years, most of which occur in low- and middle-income countries (LMICs). The adoption of the Sustainable Development Goals and their targets under the 2030 Agenda for Sustainable Development provides a new impetus for countries to accelerate tobacco control efforts as they specifically call for strengthening implementation of the World Health Organization (WHO) Framework Convention on Tobacco Control and striving to achieve a one-third reduction in premature deaths from NCDs. While NCD prevention and control is a priority in the national strategic plans and policies for health in most countries in the Western Pacific Region, few have formally adopted a national target for reducing tobacco use. Article 20 of the WHO FCTC calls on all countries to improve tobacco surveillance to enable monitoring and evaluation of tobacco control efforts. The increase in timely and standardized comparable data presents new opportunities to set scientifically valid and achievable national indicators and targets for development and implementation of strong tobacco control measures. Cambodia is yet to establish national targets and full implementation of legislative measures. However, with strong tobacco surveillance mechanism in place, it can provide the country experience for a LMIC that has developed its own capacity to conduct periodic monitoring and surveillance of tobacco use and for using national data to advocate successfully for stronger tobacco control policies.

Social Determinants of Health and Tobacco Use in Five Low and Middle-Income Countries - Results from the Global Adult Tobacco Survey (GATS), 2011 - 2012.

BACKGROUND: Tobacco consumption continues to be the leading cause of preventable deaths globally. The objective of this study was to examine the associaton of selected socio-demographic variables with current tobacco use in five countries that participated in the Phase II Global Adult Tobacco Survey in 2011 - 2012. MATERIALS AND METHODS: We analysed internationally comparable representative household survey data from 33,482 respondents aged ≥ 15 years in Indonesia, Malaysia, Romania, Argentina and Nigeria for determinants of tobacco use within each country. Socio-demographic variables analysed included gender, age, residency, education, wealth index and awareness of smoking health consequences. Current tobacco use was defined as smoking or use of smokeless tobacco daily or occasionally. RESULTS: The overall prevalence of tobacco use varied from 5.5% in Nigeria to 35.7% in Indonesia and was significantly higher among males than females in all five countries. Odds ratios for current tobacco use were significantly higher among males for all countries [with the greatest odds among Indonesian men (OR=67.4, 95% CI: 51.2-88.7)] and among urban dwellers in Romania. The odds of current tobacco use decreased as age increased for all countries except Nigeria where. The reverse was true for Argentina and Nigeria. Significant trends for decreasing tobacco use with increasing educational levels and wealth index were seen in Indonesia, Malaysia and Romania. Significant negative associations between current tobacco use and awareness of adverse health consequences of smoking were found in all countries except Argentina. CONCLUSIONS: Males and the socially and economically disadvantaged populations are at the greatest risk of tobacco use. Tobacco control interventions maybe tailored to this segment of population and incorporate educational interventions to increase knowledge of adverse health consequences of smoking.

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.

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.

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.

Developing a model of evidence-based public health practice that makes sense for the Pacific.

The new paradigm for public service organizations is summed up in the phrase "evidence-based practice," a concept grown from its origin in clinical medical practice to include a broad range of disciplines, including non-clinical approaches to disease prevention and health promotion. From a "global" perspective, this movement reflects the modernization policies of national governments that are intended to ensure effectiveness and increase accountability of publicly funded programs. It has also been fueled by rapid developments in information technology and the burgeoning growth in evidence-based research that forms the foundation of the movement. As the concept of evidence-based public health (EBPH) is exported to the Pacific, it will be imperative to keep in mind the historical and political forces that have shaped this movement, as these have important implications for attempts to advance the use of EBPH in Pacific Island communities. This commentary describes the basic format and evaluation results from an early attempt to introduce EBPH to public health workers in the Pacific at a 2-day workshop conducted at the Pacific Global Health Conference, June 13-14, 2005. This article will conclude with recommendations for developing a culturally competent model for promoting EBPH practice among public health workers and policy makers who serve Pacific Island communities.

The Influence of Obesity on the Self-Reported Health Status of Chamorros and other Residents of Guam.

PURPOSE OF THE PAPER. We report on an analysis of the relationship of obesity to self-assessments of physical health for a probability sample of Guam's indigenous (Chamorro) and resident populations. Further, we examine whether Guam's populations fit a Western model, in terms of viewing obesity as an unhealthy condition. As background for our analysis, we review the literature on (1) the relationship between obesity and chronic noninfectious diseases; (2) social and behavioral associations of obesity; and (3) the reliability of self-assessed physical health and measures of obesity. METHODS. The data analyzed were taken from a Behavioral Risk Factor Survery (BRFS) conducted on Guam in 1991. We employed various standard univariate (chi-square analysis, ANOVA) and multivariate (OLS regression and logisitic regression analusis) statistical procedures in exploring our data and testing hypotheses on the correlates and associations of self-reported health and obesity. PRINCIPAL FINDINGS. Controlling for ethnicity, age, gender, marital and socioeconomic status, we found that obesity and being Chamorro was associated significantly with low assessments of physical health and that income was a signifcant predictor of higher self-assessments. A small sample of Micronesians, with a slightly greater level of obesity than the Chamorros, did not show the same tendency towards lower self-evaluation of their health. This probably reflects their lesser degree of internalizaition of Western ideas about obesity, appearance and health. When controlling for self-assessments of physical health, obesity was also shown to be related significantly with dieting by Chamorro women but was not a significant predictor of their increased participation in physical exercise. Young males were significantly more likely to report participation in physical exercise regardless of their weight or ethnicity. CONCLUSIONS. We hypothesize that historical (acculturative) changes to the diet and life ways of Chamorros, together with a likely genetic predisposition to store fat, has led to the relatively high levels of obesity seen on Guam today. Because of internalization of Western ideals about obesity and appearance, and increased community awareness of the health perils of obesity, Chamorros are at a public health crossroads. Effective health interventions must reckon with powerful genetic and cultural cross-currents. RELEVANCE TO ASIAN PACIFIC ISLANDER AMERICAN POPULATIONS. Colleagues are encouraged to examine the effects of ethnicity and acculturation on the health attitudes, behaviors, and status of other Pacific Islander and Asian populations. The creation of such a comparative data base will service APIA health interventions. KEY WORDS. Guam, Chamorros, Asian Pacific Islander Americans, survey, obesity, self-evaluated health status, socioeconomic status, cross-cultural comparisons.