Social Determinants of Health and Tobacco Use in Thirteen Low and Middle Income Countries: Evidence from Global Adult Tobacco Survey

BACKGROUND: Tobacco use has been identified as the single biggest cause of inequality in morbidity. The objective of this study is to examine the role of social determinants on current tobacco use in thirteen low-and-middle income countries. METHODOLOGY/PRINCIPAL FINDINGS: We used nationally representative data from the Global Adult Tobacco Survey (GATS) conducted during 2008-2010 in 13 low-and-middle income countries: Bangladesh, China, Egypt, India, Mexico, Philippines, Poland, Russian Federation, Thailand, Turkey, Ukraine, Uruguay, and Viet Nam. These surveys provided information on 209,027 respondent's aged 15 years and above and the country datasets were analyzed individually for estimating current tobacco use across various socio-demographic factors (gender, age, place of residence, education, wealth index, and knowledge on harmful effects of smoking). Multiple logistic regression analysis was used to predict the impact of these determinants on current tobacco use status. Current tobacco use was defined as current smoking or use of smokeless tobacco, either daily or occasionally. Former smokers were excluded from the analysis. Adjusted odds ratios for current tobacco use after controlling other cofactors, was significantly higher for males across all countries and for urban areas in eight of the 13 countries. For educational level, the trend was significant in Bangladesh, Egypt, India, Philippines and Thailand demonstrating decreasing prevalence of tobacco use with increasing levels of education. For wealth index, the trend of decreasing prevalence of tobacco use with increasing wealth was significant for Bangladesh, India, Philippines, Thailand, Turkey, Ukraine, Uruguay and Viet Nam. The trend of decreasing prevalence with increasing levels of knowledge on harmful effects of smoking was significant in China, India, Philippines, Poland, Russian Federation, Thailand, Ukraine and Viet Nam. CONCLUSIONS/SIGNIFICANCE: These findings demonstrate a significant but varied role of social determinants on current tobacco use within and across countries

A cross-country comparison of secondhand smoke exposure in public places among adults in five African countries - The Global Adult Tobacco Survey, 2012 - 2015

Background Secondhand smoke (SHS) causes approximately 600,000 deaths annually worldwide. Timely surveillance can inform the development and enforcement of comprehensive smoke-free policies in indoor public places; yet, in many African countries, there is limited data on SHS exposure in this environment. This study examined self-reported SHS exposure in public places in five African countries. Methods Data from the Global Adult Tobacco Survey (GATS) were analyzed for Cameroon (2013), Kenya (2014), Nigeria (2012), Senegal (2015), and Uganda (2013). GATS is a standardized, nationally representative household survey of individuals aged ≥15 years. Point prevalence estimates for past 30-day SHS exposure were assessed for the following environments: bars/nightclubs, restaurants, government buildings, public transportation, and healthcare facilities. Analyses were restricted to persons who reported visiting each environment. Estimates were calculated separately for all adults and nonsmokers; nonsmokers were defined as those who answered “not at all” to the question, “Do you currently smoke tobacco on a daily basis, less than daily, or not at all?” Data were weighted and analyzed using SPSS V.24. Results Among all adults who visited each environment, country-specific SHS exposure ranged as follows: bars/nightclubs, 86.1% (Kenya) to 62.3% (Uganda); restaurants, 31.9% (Cameroon) to 16.0% (Uganda); government buildings, 24.2% (Senegal) to 5.7 % (Uganda); public transportation, 22.9% (Cameroon) to 7.8% (Uganda); and healthcare facilities, 10.2% (Senegal) to 4.5% (Uganda). SHS exposure among nonsmokers was as follows: bars/nightclubs, 85.6% (Kenya) to 60.9% (Uganda); restaurants, 32.0% (Cameroon) to 16.1% (Uganda); government buildings, 24.2% (Senegal) to 5.8 % (Uganda); public transportation, 22.2% (Cameroon) to 7.7% (Uganda); and healthcare facilities, 9.9% (Senegal) to 4.5% (Uganda). Conclusions In the assessed African countries, SHS exposure was lowest in healthcare facilities and highest in bars/nightclubs. Smoke-free policies in indoor public places, consistent with the World Health Organization's MPOWER framework, are important to protect nonsmokers from SHS exposure

Tobacco use among youth and adults in member countries of South-East Asia region: Review of findings from surveys under the global tobacco surveillance system

Background: This paper examines the prevalence of current tobacco use among youth and adults in selected member countries of the South-East Asia Region using the data from school and household-based surveys included in the Global Tobacco Surveillance System. Materials and Methods: Global Youth Tobacco Survey (GYTS) data (years 2007-2009) were used to examine current tobacco use prevalence among youth, whereas Global Adult Tobacco Survey (GATS) data (years 2009-2010) were used to examine the prevalence among adults. GYTS is a school-based survey of students aged 13-15, using a two-stage cluster sample design, and GATS is a household survey of adults age 15 and above using a multi-stage stratified cluster design. Both surveys used a standard protocol for the questionnaire, data collection and analysis. Results: Prevalence of current tobacco use among students aged 13-15 varied from 5.9% in Bangladesh to 56.5% in Timor-Leste, and the prevalence among adults aged 15 and above was highest in Bangladesh (43.3%), followed by India (34.6%) and Thailand (27.2%). Reported prevalence was significantly higher among males than females for adults and youth in all countries except Bangladesh, Sri Lanka and Timor-Leste. Current use of tobacco other than manufactured cigarettes was notably higher than current cigarette smoking among youth aged 13-15 years in most countries of the Region, while the same was observed among adults in Bangladesh, India and Thailand, with most women in those countries, and 49% of men in India, using smokeless tobacco. Conclusion: Tobacco use among youth and adults in member countries of the region is high and the pattern of tobacco consumption is complex. Tobacco products other than cigarettes are commonly used by youth and adults, as those products are relatively cheaper than cigarettes and affordable for almost all segments of the population. As a result, use of locally produced smoked and smokeless tobacco products is high in the region. Generating reliable data on tobacco use and key tobacco control measures at regular intervals is essential to better understand and respond with effective tobacco control intervention

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)

Electronic Data Collection and Management System for Global Adult Tobacco Survey

INTRODUCTION: Portable handheld computers and electronic data management systems have been used for national surveys in many high-income countries, however their use in developing countries has been challenging due to varying geographical, economic, climatic, political and cultural environments. In order to monitor and measure global adult tobacco use, the World Health Organization and the US Centers for Disease Control and Prevention initiated the Global Adult Tobacco Survey, a nationally representative household survey of adults, 15 years of age or older, using a standard core questionnaire, sample design, and data collection and management procedures. The Survey has been conducted in 14 low- and middle-income countries, using an electronic data collection and management system. This paper describes implementation of the electronic data collection system and associated findings. METHODS: The Survey was based on a comprehensive data management protocol, to enable standardized, globally comparable high quality data collection and management. It included adaptation to specific country needs, selection of appropriate handheld hardware devices, use of open source software, and building country capacity and provide technical support. RESULTS: In its first phase, the Global Adult Tobacco Survey was successfully conducted between 2008 and 2010, using an electronic data collection and management system for interviews in 302,800 households in 14 countries. More than 2,644 handheld computers were fielded and over 2,634 fieldworkers, supervisors and monitors were trained to use them. Questionnaires were developed and programmed in 38 languages and scripts. The global hardware failure rate was < 1% and data loss was almost 0%. CONCLUSION: Electronic data collection and management systems can be used effectively for conducting nationally representative surveys, particularly in low- and middle-income countries, irrespective of geographical, climatic, political and cultural environments, and capacity-building at the country level is an important vehicle for Health System Strengthening

Exposure to tobacco smoke among adults in Bangladesh

Objective: To examine exposure to second-hand smoke (SHS) at home, in workplace, and in various public places in Bangladesh. Materials and Methods: Data from 2009 Global Adult Tobacco Survey (GATS) conducted in Bangladesh was analyzed. The data consists of 9,629 respondents from a nationally representative multi-stage probability sample of adults aged 15 years and above. Exposure to second-hand smoke was defined as respondents who reported being exposed to tobacco smoke in the following locations: Indoor workplaces, homes, government building or office, health care facilities, public transportation, schools, universities, restaurants, and cafes, coffee shops or tea houses. Exposure to tobacco smoke in these places was examined by gender across various socioeconomic and demographic sub-groups that include age, residence, education and wealth index using SPSS 17.0 for complex samples. Results: The study shows high prevalence of SHS exposure at home and in workplace and in public places. Exposure to SHS among adults was reported high at home (54.9%) (male-58.2% and female-51.7%), in workplace (63%) (male-67.8% and female-30.4%), and in any public place (57.8%) (male-90.4% and female-25.1%) 30 days preceding the survey. Among the public places examined exposure was low in the educational institutions (schools-4.3%) and health care facilities (5.8%); however, exposure was high in public transportation (26.3%), and restaurants (27.6%). SHS exposure levels at home, in workplace and public places were varied widely across various socioeconomic and demographic sub-groups. Conclusions: Exposure was reported high in settings having partial ban as compared to settings having a complete ban. Following the WHO FCTC and MPOWER measures, strengthening smoke-free legislation may further the efforts in Bangladesh towards creating and enforcing 100% smoke-free areas and educating the public about the dangers of SHS. Combining these efforts can have a complementary effect on protecting the people from hazardous effect of SHS as well as reducing the social acceptance of smoking both at home and in public and workplaces. Ongoing surveillance in Bangladesh is necessary to measure progress towards monitoring SHS exposure

Awareness and use of electronic cigarettes among youth: evidence from the Global Youth Tobacco Survey 2012 - 2015

Background Globally, evidence on the awareness and use of electronic cigarettes (e-cigarettes) is limited. We examined the awareness and current use of e-cigarettes among male and female students aged 13-15 years old across 16 countries or regions that conducted the Global Youth Tobacco Survey (GYTS). Methods GYTS is a cross-sectional, nationally representative, school-based survey of students aged 13-15 years. Data from the16 countries or regions were used to examine student awareness (ever heard of) and current use (in the past 30 days) of e-cigarettes. Sample sizes across the 16 countries or regions ranged from 962 in Georgia to 5,153 in Paraguay and response rates ranged from 75.4% in Georgia to 99.2% in Sudan. Weighted point estimates and 95% confidence intervals (CI) were calculated and statistically significant differences (p< 0.05) by gender were assessed using a two-sample t-test. Results Awareness of e-cigarettes ranged from 19.6% (95% CI: 16.1-23.6) in Peru to 93.0% (95% CI: 91.4-94.3) in the Moscow region of Russia. Across all sites, only Seychelles and United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) had significantly higher awareness of e-cigarette among boys than girls. Current use of e-cigarettes ranged from 1.6% (95% CI: 1.1-2.5) in Kazakhstan to 15.4% (95% CI: 12.6-18.5) in UNRWA. In Albania, Belize, Macao, Seychelles, and UNRWA, boys had a significantly higher prevalence of current e-cigarette use than girls. Conclusions The findings show that awareness and use of e-cigarettes varies considerably across 16 countries/regions. GYTS is a viable platform to measure tobacco use among youth, including emerging products such as e-cigarettes