Smoking, smoking cessation, and 7-year mortality in a cohort of Thai adults

BACKGROUND: Smoking is a strong risk factor for mortality in both the developed and the developing world. However, there is still limited research to examine the impact of smoking cessation and mortality in middle-income Southeast Asian populations. METHODS: We use longitudinal data from a large Thai cohort of adult Open University students residing nationwide, linked with official death records to assess the association of smoking status and mortality risks during a 7-year follow-up. The log-rank test was used to evaluate the statistical probability of differential survival according to baseline smoking status. Multivariate hazard ratios (HR) were reported for smoking status and all-cause and cause-specific mortality. RESULTS: From 2005 baseline to 2012, current smokers were more likely to die than cohort members who ceased smoking and never smokers (1.9 vs 1.3 vs 0.6 %, p < 0.05). The hazard of all-cause mortality increased with the daily amount of cigarette consumption among both current and former smokers. Cause of death analyses showed that current male smokers had a significantly increased risk of cardiovascular disease related mortality (HR 3.9 [95 % CI 1.8–8.1]). Former male smokers had a moderate increase in risk of dying from cardiovascular diseases compared to never smokers (HR 1.6 [95 % CI 0.7–3.4]). Current male smokers between 2005 and 2009 experienced highest subsequent mortality hazards during the period 2009–2012 compared to never smokers (HR 2.1 [95 % CI 1.4–3.4]). The higher risk of dying reduced if people quit smoking during the 2005–2009 follow-up period (HR 1.5 [95 % CI 0.7–3.3]). Risk for mortality fell even further among long-term quitters (HR 1.4 [95 % CI 0.9–2.2]). CONCLUSION: Among a large nationwide cohort of Thai adults, current smokers were at a significantly and substantially higher risk of all-cause mortality, especially cardiovascular-related mortality. The higher risk of dying fell if people quit smoking and the risk for mortality was even lower among long-term quitters. Promotion of smoking cessation will contribute substantially to the reduction in avoidable mortality in Thailand.This study was supported by the International Collaborative Research Grants Scheme with joint grants from the Wellcome Trust UK (GR071587MA) and the Australian National Health and Medical Research Council (268055), and as a global health grant from the NHMRC (585426)

Expertise in research integration and implementation for tackling complex problems: when is it needed, where can it be found and how can it be strengthened?

© 2020, The Author(s). Expertise in research integration and implementation is an essential but often overlooked component of tackling complex societal and environmental problems. We focus on expertise relevant to any complex problem, especially contributory expertise, divided into ‘knowing-that’ and ‘knowing-how.’ We also deal with interactional expertise and the fact that much expertise is tacit. We explore three questions. First, in examining ‘when is expertise in research integration and implementation required?,’ we review tasks essential (a) to developing more comprehensive understandings of complex problems, plus possible ways to address them, and (b) for supporting implementation of those understandings into government policy, community practice, business and social innovation, or other initiatives. Second, in considering ‘where can expertise in research integration and implementation currently be found?,’ we describe three realms: (a) specific approaches, including interdisciplinarity, transdisciplinarity, systems thinking and sustainability science; (b) case-based experience that is independent of these specific approaches; and (c) research examining elements of integration and implementation, specifically considering unknowns and fostering innovation. We highlight examples of expertise in each realm and demonstrate how fragmentation currently precludes clear identification of research integration and implementation expertise. Third, in exploring ‘what is required to strengthen expertise in research integration and implementation?,’ we propose building a knowledge bank. We delve into three key challenges: compiling existing expertise, indexing and organising the expertise to make it widely accessible, and understanding and overcoming the core reasons for the existing fragmentation. A growing knowledge bank of expertise in research integration and implementation on the one hand, and accumulating success in addressing complex societal and environmental problems on the other, will form a virtuous cycle so that each strengthens the other. Building a coalition of researchers and institutions will ensure this expertise and its application are valued and sustained

International service trade and its implications for human resources for health: a case study of Thailand

This study aims at analysing the impact of international service trade on the health care system, particularly in terms of human resources for health (HRH), using Thailand as a case study. Information was gathered through a literature review and interviews of relevant experts, as well as a brainstorming session. It was found that international service trade has greatly affected the Thai health care system and its HRH. From 1965 to 1975 there was massive emigration of physicians from Thailand in response to increasing demand in the United States of America. The country lost about 1,500 physicians, 20% of its total number, during that period. External migration of health professionals occurred without relation to agreements on trade in services. It was also found that free trade in service sectors other than health could seriously affect the health care system and HRH. Free trade in financial services with free flow of low-interest foreign loans, which started in 1993 in Thailand, resulted in the mushrooming of urban private hospitals between 1994 and 1997. This was followed by intensive internal migration of health professionals from rural public to urban private hospitals. After the economic crisis in 1997, with the resulting downturn of the private health sector, reverse brain drain was evident. At the same time, foreign investors started to invest in the bankrupt private hospitals. Since 2001, the return of economic growth and the influx of foreign patients have started another round of internal brain drain

Smoking in Thailand : a comparison of a large national sentinel cohort to the Thai population and projected future mortality

This Thesis focuses on the public health problem of smoking in Thailand. It analyses smoking patterns among adult open-university students and compares them with the pattern in the general Thai population. Smoking and implications for the future burden of disease and the opportunity for effective interventions are addressed. Smoking rates among the open-university students were estimated from a questionnaire administered to a large national cohort of students enrolled at Sukhothai Thammathirat Open University (STOU) in 2005. In the general Thai population smoking patterns were derived from the Third National Health Examination Survey (NHESIII) conducted nationwide in Thailand in 2004. Among the 80,543 open-university students aged 15-60 years at the time of the survey, 21.2 percent of male students and around 1.0 percent of female students reported currently smoking. Around 4.5 percent of female but 34.8 percent of male students were former smokers. The proportion of former male smokers increased with age; more older respondents had quit smoking than younger ones. Most students started smoking at school age. More recent birth cohorts on average started smoking at an earlier age than the older birth cohorts. Surprisingly, the study found a negative relation between starting smoking at school age and parents' education. The higher the education level of the parents, the higher the rate of starting smoking at school age. Smoking behaviour among the open-university students was then compared to that of the national Thai population using data from the Third National Health Examination Survey (NHESIII). A total of 20,555 individuals of the population aged 15-60 years under the NHESIII were covered in the comparison. Both samples have a very similar geographic distribution with the exception that the open-university students had a higher proportion from Bangkok. The students however had higher levels of education, lower marriage rates and slightly higher incomes than the general population. After adjusting for personal income, marital status and geographic region the male national population had 1.6 times higher smoking rates than the open-university students, and the female national population had 1.2 times higher rates. Both the male and female national population groups also smoked more than the students in all education categories except for the female population with a university degree who smoked slightly less than the female open-university students. The Thesis also gives an estimation of the cumulative future healthy life years lost due to morbidity (years lived with disability or YLD) and pre-mature mortality (years of life lost or YLL) attributable to smoking. Expected morbidity and mortality associated with 10 smoking-related diseases were applied to the Thai data at hand using burden of disease techniques assuming present smoking rates continued. It was found that a 25 year old male smoker would lose 11.8 years due to premature mortality or if he quit smoking, he would gain 9.9 years. A 25 year old female smoker would lose 7.6 years due to premature mortality or like a male smoker, she would gain 7.5 years if she quit smoking. In addition, the same male smoker would lose 0.8 healthy years due to smoking related diseases and the same female smoker would lose 1.8 healthy years. Among 25-29 year old male smokers in the student cohort, with this projection, a total loss of 25,477 healthy years due to premature mortality caused by smoking could be expected. In addition, a total loss of 1,072 healthy years could be expected among student female smokers of the same ages. In the past two decades a reduction in smoking prevalence has been observed in Thailand. Accordingly, based on actual decreases in smoking rates in the past 15 years and the effects of cigarette excise taxes on reducing smoking rates, the Thesis projected falling smoking prevalences and total healthy life years lost due to smoking. Findings from this comparison of smoking behaviour reveal the powerful association between education and lower rates of smoking, after adjusting for other factors, thus supporting the potential role of education in reducing smoking rates in Thailand. The findings also provide the STOU and other tertiary institutions with useful information on smoking behaviour among their students.thus assisting with awareness raising measures regarding health risk behaviours among both non smokers and current smokers. Smoking prevalence is still high in Thailand despite the nation-wide implementation of tobacco control policies. So, further research is needed. For example, the baseline questionnaire used here should be repeated in order to measure changes in smoking behaviour over time and examine reasons for the change. The repeated survey should, in addition to repeating the same questions, cover additional issues. Topics of special interest include the behavioural and psychological condition of smokers and non-smokers, reasons for smoking initiation and cessation and non-initiation, attitude toward smoking, perception of smoking effects on health and types of tobacco smoked

Timing of urbanisation and cardiovascular risks in Thailand: Evidence from 51 936 members of the Thai Cohort Study, 2005-2009

Background: Urban populations usually have higher levels of cardiovascular risk factors than rural populations in developing countries. However, association between cardiovascular risk factors and duration of urban dwelling, particularly for early stage

Health risk factors and the incidence of hypertension: 4-Year prospective findings from a national cohort of 60 569 Thai Open University students

Objective: This study evaluates the impact of a number of demographic, biological, behavioural and lifestyle health risk factors on the incidence of hypertension in Thailand over a 4-year period