National Tobacco Control Program Research Articles

Mixed-Methods for Comparing Tobacco Cessation Interventions.

The National Comprehensive Cancer Control Program (NCCCP) and National Tobacco Control Program (NTCP) are both well-positioned to promote the use of population-based tobacco cessation interventions, such as state quitlines and Web-based interventions. This paper outlines the methodology used to conduct a comparative effectiveness research study of traditional and Web-based tobacco cessation and quitline promotion approaches. A mixed-methods study with three components was designed to address the effect of promotional activities on service usage and the comparative effectiveness of population-based smoking cessation activities across multiple states. The cessation intervention component followed 7,902 smokers (4,307 quitline users and 3,595 Web intervention users) to ascertain prevalence of 30-day abstinence rates 7 months after registering for smoking cessation services. User characteristics and quit success was compared across the two modalities. In the promotions component, reach and use of traditional and innovative promotion strategies were assessed for 24 states, including online advertising, state Web sites, social media, mobile applications, and their effects on quitline call volume. The partnership intervention component studied the extent of collaboration among six selected NCCCPs and NTCPs. This study will guide program staff and clinicians with evidence-based recommendations and best practices for implementation of tobacco cessation within their patient and community populations and establish an evidence base that can be used for decision making.

Has the attitude of school students toward smoking changed after a decade since the framework convention of tobacco control?

Sir, Nearly 6 million people die globally due to tobacco use and more than 63% of all deaths due to non-communicable diseases (NCDs) are related to tobacco use.[1] The WHO Framework Convention on Tobacco Control (WHO FCTC) is an international treaty adopted by the World Health Assembly on 21 May 2003. The WHO FCTC was developed in response to the globalization of the tobacco epidemic.[2] WHO introduced the MPOWER measures which are intended to assist in the country-level implementation of effective interventions to reduce the demand for tobacco, contained in the WHO FCTC.[3] India is one the signatories of the WHO FCTC and also has introduced many of the intervention measures suggested by FCTC which include Cigarettes and Other Tobacco Products Act, 2003 (COTPA)[4] and National Tobacco Control Program.[5] We intended to study the perception and attitude of school students toward tobacco use after a decade of efforts against tobacco use. A cross-sectional study was done between January and March 2012 in one of the higher secondary schools of rural Puducherry. Five schools in rural area within a 20-km radius from JIPMER were approached and only one school consented to participate in the study. The school was a private, English medium school with over 1000 students. There were a total of 233 students belonging to 8th, 9th and 10th(age group 13-15 years as included in Global Youth Tobacco Surveys) class. We included all the students who were present on the day of survey (N = 200) in the school from these three classes. Informed consent from the Principal of the school and Institutional Ethics Committee clearance was obtained for the study. On the survey day, the students were made to assemble in a hall and the Global Youth Tobacco Survey Core questionnaire (GYTS core questionnaire) was distributed to them. As the school's medium of education was English, the questionnaire was provided in English. Confidentiality and anonymity of the data collected were assured. Adequate time was provided for completion of the questionnaire. Data were analysed using SPSS (Statistical package for Social Sciences) version 16. All proportions were reported as percentages. Of the 200 students, 183 returned complete data collection forms and hence only they were included for analysis. Girls constituted 58.5% (107) of the study population. It was found that current use of tobacco in any form was seen in 12.6% of the students (Boys: 23.7%; Girls: 4.7%). Current use of smokeless form of tobacco was found among 6.6% of the students (Boys: 11.8%; Girls: 2.8%). Just more than half of the students (53.6%) felt that cigarette smoking is definitely harmful to health (Boys: 56.6%; Girls: 51.4%). The rest were not too sure and said that it may probably be harmful or harmless. The proportion of students who felt that second hand smoke was definitely harmful was found to be only 41% (Boys: 38.2%; Girls: 43%). A higher proportion of girls (76.6%) said that they would not smoke a cigarette in the next 5 years when compared to boys (51.3%). Only a very small proportion (<10%) of the students felt that smoking would result in more friends or make a person more attractive or comfortable at social gatherings. However, at least one-fourth of the students felt that smoking status made no difference in the number of friends one would have or in the attractiveness of an individual [Table 1].Table 1: Attitude toward tobacco use among students of a school in rural PuducherryTherefore, 10 years after WHO FCTC, the prevalence of tobacco use is similar to the national average studied in 2006.[6] Even after a decade of interventions, a section of the students have still not grasped the harmful effects of tobacco use and have a neutral attitude toward smoking and smokers. Hence efforts toward tobacco control needs to be revisited. Thank You.

Impact of modular training on tobacco control on the knowledge of health workers in two jurisdictions of northern India.

National Tobacco Control Programme was launched in India in year 2007-08. It was realized that community health workers can play an important role of agents for positive change to bring down the tobacco morbidity and mortality in the country. Keeping this in view, a health worker guide was developed by the Government of India, Ministry of Health and Family Welfare (GOI) in collaboration with The Union South-East Asia (The Union) in the year 2010. The guide provides the information needed by the most basic level of health workers to effectively address the problem of tobacco use in the community. A modular training was conducted in two jurisdictions in India (namely, Chandigarh and Hamirpur (Himachal Pradesh)) to assess the usefulness of the guide as training material for community health workers in undertaking tobacco control activities at community and village levels. A total of 271 participants were trained, which included 133 from Chandigarh and 138 from Hamirpur. The pre and post-training assessment of knowledge of health worker was done. There was marked increase in post-test scores as compared to the pretest scores. The health workers scoring more than 60% increased from 40% in the pretest to over 80% in the post-test. Only three workers had a post-test score of less than 30% against 54 workers in the pretest. The understanding on tobacco control had increased significantly after the training in each group. It is strongly recommended that such training should be replicated to all community health workers across all the states in India.

Barriers to the provision of smoking cessation assistance: a qualitative study among Romanian family physicians.

Background:Smoking cessation is the most effective intervention to prevent and slow down the progression of several respiratory and other diseases and improve patient outcomes. Romania has legislation and a national tobacco control programme in line with the World Health Organization Framework for Tobacco Control. However, few smokers are advised to quit by their family physicians (FPs).Aim:To identify and explore the perceived barriers that prevent Romanian FPs from engaging in smoking cessation with patients.Methods:A qualitative study was undertaken. A total of 41 FPs were recruited purposively from Bucharest and rural areas within 600 km of the city. Ten FPs took part in a focus group and 31 participated in semistructured interviews. Analysis was descriptive, inductive and themed, according to the barriers experienced.Results:Five main barriers were identified: limited perceived role for FPs; lack of time during consultations; past experience and presence of disincentives; patients’ inability to afford medication; and lack of training in smoking cessation skills. Overarching these specific barriers were key themes of a medical and societal hierarchy, which undermined the FP role, stretched resources and constrained care.Conclusions:Many of the barriers described by the Romanian FPs reflected universally recognised challenges to the provision of smoking cessation advice. The context of a relatively hierarchical health-care system and limitations of time and resources exacerbated many of the problems and created new barriers that will need to be addressed if Romania is to achieve the aims of its National Programme Against Tobacco Consumption.

Actions geared to tobacco control: a review of their implementation in Primary Health Care

This survey examined the status of the implementation of policies for tobacco control in a medium-sized municipality through an assessment of actions recommended by the National Tobacco Control Program (NTCP) promoted by Primary Health Care (PHC) units. The coordinator of the local NTCP and professionals from 44 PHC units of Juiz de Fora in the state of Minas Gerais were interviewed, between May and July 2011. It was observed that the actions of treatment and health promotion were being duly executed, the highlight being the training of professionals to implement treatment in PHC. In 40.9%, there is the provision of treatment for smokers, and in 88.6% the actions are concentrated in activities in waiting rooms, groups and individual consultations. Limitations identified are probably not restricted to the municipality, such as inadequate structuring of units, high turnover, the varying degree of involvement of professionals in implementing the service and also the lack of mechanisms to enable them to implement and give continuity to care among their other responsibilities. The major challenge for tobacco control is to conduct intersectoral actions and in primary health care. The results can serve for the formulation of strategic health actions in other parts of the country.

Bayesian spatio-temporal modelling of tobacco-related cancer mortality in Switzerland

Tobacco smoking is a main cause of disease in Switzerland; lung cancer being the most common cancer mortality in men and the second most common in women. Although disease-specific mortality is decreasing in men, it is steadily increasing in women. The four language regions in this country might play a role in this context as they are influenced in different ways by the cultural and social behaviour of neighbouring countries. Bayesian hierarchical spatio-temporal, negative binomial models were fitted on subgroup-specific death rates indirectly standardized by national references to explore age- and gender-specific spatio-temporal patterns of mortality due to lung cancer and other tobacco-related cancers in Switzerland for the time period 1969-2002. Differences influenced by linguistic region and life in rural or urban areas were also accounted for. Male lung cancer mortality was found to be rather homogeneous in space, whereas women were confirmed to be more affected in urban regions. Compared to the German-speaking part, female mortality was higher in the French-speaking part of the country, a result contradicting other reports of similar comparisons between France and Germany. The spatio-temporal patterns of mortality were similar for lung cancer and other tobacco-related cancers. The estimated mortality maps can support the planning in health care services and evaluation of a national tobacco control programme. Better understanding of spatial and temporal variation of cancer of the lung and other tobacco-related cancers may help in allocating resources for more effective screening, diagnosis and therapy. The methodology can be applied to similar studies in other settings.

Tobacco-related cancer mortality: projections for different geographical regions in Switzerland

Switzerland is divided into 26 cantons of variable population size and cultural characteristics. Although a federal law to protect against passive smoking and a national tobacco control programme exist, details of tobacco-related policies are canton-specific. This study aimed to project gender-specific tobacco-related cancer mortality in Switzerland at different geographical levels for the periods 2009-2013 and 2014-2018. In this analysis, data on Swiss tobacco-related cancer mortality from 1984 until 2008 were used. Bayesian age-period-cohort models were formulated to assess past trends of gender-specific tobacco-related cancer mortality and to project them up to 2018 at cantonal and language region levels. Furthermore, estimates are provided on a national scale by age categories of 50-69 and ≥70 years. Model-based estimates at cantonal level identified regions with low and high tobacco-related cancer mortality rates for the observed and projected periods. Our analysis based on language regions showed the lowest mortality in the German-speaking part. Projections at national level, between younger (age 50-69) and older (age ≥70) males, indicated an ongoing decreasing trend for males but an upward trend for females. The gap in tobacco-related cancer mortality rates between younger and older males seems to be shrinking. In females, a stronger rise was obtained for the younger age group. Our findings indicate region-, sex- and age-related differences in tobacco-related cancer mortality in Switzerland and this could be useful for healthcare planning and for evaluating the impact of canton-specific tobacco-related policies and interventions.

The value of research as a component of successful tobacco control in China

Research has been shown to be a critical component of successful national tobacco control programmes. China currently has a small number of dedicated researchers addressing tobacco use and control. We...

Bayesian spatio-temporal modelling of tobacco-related cancer mortality in Switzerland

Tobacco smoking is a main cause of disease in Switzerland; lung cancer being the most common cancer mortality in men and the second most common in women. Although disease-specific mortality is decreasing in men, it is steadily increasing in women. The four language regions in this country might play a role in this context as they are influenced in different ways by the cultural and social behaviour of neighbouring countries. Bayesian hierarchical spatio-temporal, negative binomial models were fitted on subgroup-specific death rates indirectly standardized by national references to explore age- and gender-specific spatio-temporal patterns of mortality due to lung cancer and other tobacco-related cancers in Switzerland for the time period 1969-2002. Differences influenced by linguistic region and life in rural or urban areas were also accounted for. Male lung cancer mortality was found to be rather homogeneous in space, whereas women were confirmed to be more affected in urban regions. Compared to the German-speaking part, female mortality was higher in the French-speaking part of the country, a result contradicting other reports of similar comparisons between France and Germany. The spatio-temporal patterns of mortality were similar for lung cancer and other tobacco-related cancers. The estimated mortality maps can support the planning in health care services and evaluation of a national tobacco control programme. Better understanding of spatial and temporal variation of cancer of the lung and other tobacco-related cancers may help in allocating resources for more effective screening, diagnosis and therapy. The methodology can be applied to similar studies in other settings.

Burden of non communicable diseases in India: Setting priority for action

Non-communicable diseases (NCDs) are defined as diseases of long duration, and are generally slow in progression. NCDs are the leading cause of death in the world, responsible for 63% deaths worldwide in 2008. NCDs accounts for 53 percent of deaths in India. Based on available evidence cardiovascular diseases (24 percent), chronic respiratory diseases (11 percent), cancer (6 percent) and diabetes (2 percent) are the leading cause of mortality in India. Treatment cost is almost double for NCDs as compared to other conditions and illnesses. Burden of NCDs and resultants mortality is expected to increase unless massive efforts are made to prevent and control NCDs and their risk factors. India could develop a strategy for reducing out of pocket expenditure. Underlying determinants of NCDs mainly exist in non-health sectors, such as agriculture, urban development, education and trade. Inter-sectoral collaboration is therefore essential to create an enabling environment. Government of India had launched various vertical programmes such as National Cancer Control Programmes, National Tobacco Control Programme, National Programme for Prevention and Control of Cancer, Diabetes, CVD and Stroke (NPCDCS) etc. Strong surveillance, monitoring and evaluation system is required for successful implementation of the programmes. Public health facilities should be strengthened for providing services of screening; early diagnosis and treatment within the public health care delivery system. Efforts need to be done on implementing the clinical standards and guidelines developed under the Indian Public Health Standards (IPHS), and integrating NCD training into training curricula of health workforce.

Patterns and predictors of current cigarette smoking in women and men of reproductive age-Ecuador, El Salvador, Guatemala, and Honduras

To estimate smoking prevalence by gender, describe patterns of cigarette use, and identify predictors of current smoking in reproductive-age adults in four Latin American countries. Self-reported smoking was examined using data from Reproductive Health Surveys of women aged 15-49 years in Ecuador (2004), El Salvador (2002-2003), Guatemala (2002), and Honduras (2001), and of men aged 15-59 years in El Salvador, Guatemala, and Honduras for the same years. Current smoking was assessed by demographic characteristics, and independent associations were examined using logistic regression. Data were weighted to be nationally representative of households with reproductive-age women and men. Current smoking prevalence ranged from 2.6% (Guatemala) to 13.1% (Ecuador) for women and from 23.1% (Guatemala) to 34.9% (El Salvador) for men. In Ecuador, 67.6% of female smokers were non-daily users; in other countries, daily use was more prevalent than non-daily use for both men and women. In daily users, the median number of cigarettes smoked per day ranged from 1.9 (Ecuador, Honduras) to 2.3 (Guatemala) for women and from 2.1 (Guatemala) to 3.6 (Honduras) for men. In bivariate analysis, smoking prevalence in all countries was highest in women who lived in urban areas, were previously married, and/or had high socioeconomic status. Risk factors for smoking varied by country and gender. National tobacco control programs in these countries should aggressively target high-risk populations (reproductive-age men) and maintain low prevalence in low-risk populations (reproductive-age women). More research is needed to understand addiction patterns in non-daily smokers.

Effectiveness of health promotion in preventing tobacco use among adolescents in India

This case study has two aims. First, it describes intervention strategies from two school-based programs designed to prevent tobacco use among adolescents in India. Second, it explains how evidence from randomized controlled trials of these intervention programs was used by a local non-governmental organization in Delhi to advocate for scaling up the Government of India's tobacco control efforts to include school health interventions as one of the components of India's National Tobacco Control Program. This case study illustrates the need for developing countries to conduct rigorous evaluation in order to provide context-relevant evidence prior to scaling up interventions.

Evidence building for policy: Tobacco surveillance/surveys and research in India

India is at a crucial juncture relating to tobacco control and implementing the recommendations of the WHO FCTC. Tobacco consumption in the country remains alarmingly high in urban as well as rural areas. Smokeless tobacco consumption is very popular among larger masses, including the youth. Cigarette smoking has declined, but bidi use has increased concomitantly. Youth continue to be lured to initiate tobacco consumption through efficient marketing strategies of tobacco companies. The epidemiology of tobacco consumption is markedly varied across the country, with high rates in 15 States. Progress has been made towards tobacco control by the enactment of laws and regulations and the National Tobacco Control Program. Strengthening their implementation and enforcement is the biggest challenge and requires resource inputs. Evidence generation and its translation and utilisation for policy interventions would be useful.

Tobacco Control Policies in India: Implementation and Challenges

Tobacco use is a major public health challenge in India with 275 million adults consuming different tobacco products. Government of India has taken various initiatives for tobacco control in the country. Besides enacting comprehensive tobacco control legislation (COTPA, 2003), India was among the first few countries to ratify WHO the Framework Convention on Tobacco Control (WHO FCTC) in 2004. The National Tobacco Control Programme was piloted during the 11 th Five Year Plan which is under implementation in 42 districts of 21 states in the country. The advocacy for tobacco control by the civil society and community led initiatives has acted in synergy with tobacco control policies of the Government. Although different levels of success have been achieved by the states, non prioritization of tobacco control at the sub national level still exists and effective implementation of tobacco control policies remains largely a challenge.

Tobacco cessation services in India: Recent developments and the need for expansion

Tobacco use is a major cause of preventable death and disease in India. Unfortunately, very few people in India quit tobacco use. Lack of awareness of harm, ingrained cultural attitudes, and lack of support for cessation maintains tobacco use in the community. The significant addictive property of nicotine makes quitting difficult and relapse common. Health professionals have received little training, and very few thus carry out proper assessments and interventions among tobacco users. Evidence from the developed countries suggests that brief interventions delivered by diverse health professionals are effective in tobacco cessation. Combining pharmacologic approaches with behavioral counseling produces better results than a single strategy. In India, early experiences with tobacco cessation occurred in the context of primary community education for cancer control. More recently, tobacco cessation clinics have been set up to develop models of intervention, and train health professionals in service delivery. These need to be expanded at the primary, secondary, and tertiary care levels, and cost-effective community tobacco cessation models need to be developed. Tobacco cessation forms one of the critical activities under the National Tobacco Control Program. Tobacco cessation needs to be urgently expanded by training health professionals in providing routine clinical interventions, increasing availability and subsidy on pharmacotherapy, developing wide-reaching strategies, such as quitlines and cost-effective strategies, such as group interventions.

Using Evaluation Capacity Building (ECB) to Interpret Evaluation Strategy and Practice in the United States National Tobacco Control Program (NTCP): A Preliminary Study

Abstract: The Office on Smoking and Health (OSH) of the Centers for Disease Control and Prevention (CDC) supports state programs for the prevention and control of tobacco use through the National Tobacco Control Program (NTCP). OSH provides the NTCP with expert guidance and technical assistance on tobacco use control and disease surveillance as well as evaluation of tobacco control programs. These services fit national health goals and provide data to inform national and state policy making and program planning. However, the NTCP’s delivery of services, achievement of goals, and evaluation of efforts is hindered by fluctuations in dedicated state funds to support tobacco use prevention and control programs. To maximize effort and resources, evaluation capacity building (ECB) is a strategy for strengthening evaluation services, program efficiency, and program effectiveness, that is, program improvement. This article interprets NTCP using an ECB frame to learn the utility of this approach for making suggestions for structural and practice changes that lead to program improvement.

A Review of Economic Evaluations of Tobacco Control Programs

Each year, an estimated 443,000 people die of smoking-related diseases in the United States. Cigarette smoking results in more than $193 billion in medical costs and productivity losses annually. In an effort to reduce this burden, many states, the federal government, and several national organizations fund tobacco control programs and policies. For this report we reviewed existing literature on economic evaluations of tobacco control interventions. We found that smoking cessation therapies, including nicotine replacement therapy (NRT) and self-help are most commonly studied. There are far fewer studies on other important interventions, such as price and tax increases, media campaigns, smoke free air laws and workplace smoking interventions, quitlines, youth access enforcement, school-based programs, and community-based programs. Although there are obvious gaps in the literature, the existing studies show in almost every case that tobacco control programs and policies are either cost-saving or highly cost-effective.

Changes in Tobacco Use among 13-15-year-olds in the Czech Republic - 2002 and 2007

The Czech Republic is a member of the European Union (EU) and the World Health Organization (WHO). The EU has made tobacco use prevention a primary health issue and WHO European Region has adopted the European Strategy for Tobacco Control. The aim of the current study is to evaluate the status of tobacco use among adolescents in the Czech Republic and relate these findings to the tobacco control programme efforts supported by the EU and WHO. Global Youth Tobacco Survey (GYTS) data were collected from representative samples of students in grades associated with ages 13-15 in the Czech Republic in 2002 and 2007. Current cigarette smoking decreased from 35% to 31% overall. Exposure to second-hand smoke (SHS) in public places remained unchanged over time (75% in 2007). Almost half of respondents reported having a parent who smokes and about one third had best friends who smoked. There were significant decreases in exposure to pro-tobacco advertisements on billboards in magazines. Efforts to reduce the current and projected harm caused by tobacco use in the Czech Republic are urgently needed. The Czech Republic needs to expand its national comprehensive tobacco prevention and control programmes and enforce those laws already passed. Without this effort little reduction can be expected in the burden of chronic diseases and tobacco-related mortality. What this paper adds. Results from the GYTS conducted in the Czech Republic indicate a number of serious challenges to prevent and control tobacco use in the region despite a range of ongoing tobacco control activities. GYTS data can enhance countries' capacity to monitor tobacco use among youth; guide development, implementation, and evaluation of their national tobacco prevention and control programme; and allow comparison of tobacco-related data at the national, regional, and global levels.

The Global Youth Tobacco Survey (GYTS): linking data to the implementation of the WHO Framework Convention on Tobacco Control

The World Health Organization (WHO), the US Centers for Disease Control and Prevention, and the Canadian Public Health Association developed the Global Tobacco Surveillance System (GTSS) to assist WHO member states in establishing continuous tobacco control surveillance and monitoring. The GTSS provides a flexible system that includes common data items but allows countries to include important unique information at their discretion. It also uses a common survey methodology, similar field procedures for data collection, and similar data management and processing techniques. The GTSS includes collection of data through three surveys: the Global Youth Tobacco Survey (GYTS) for youth, and the Global School Personnel Survey and the Global Health Professional Student Survey for adults. Countries can use data from the GYTS to monitor and evaluate National Tobacco Control Action Plans and articles from the WHO Framework Convention on Tobacco Control (WHO FCTC). The WHO FCTC was adopted by the 56th World Health Assembly in May 2003 and became international law on February 27, 2005. It is the world's first public health treaty on tobacco control and encourages countries that ratify to develop and implement tobacco control policies, such as bans on direct and indirect tobacco advertising, tobacco tax and price increases, promoting of smoke-free public places and workplaces, and placement of health messages on tobacco packaging. The WHO FCTC, National Tobacco Control Action Plans, and the GYTS share the same goal: the development, implementation, and evaluation of effective tobacco control programs in all WHO member states. What the WHO FCTC and National Tobacco Control Action Plans ask countries to monitor, the GYTS can help to measure. The GYTS provides indicators for measuring achievement of several WHO FCTC articles (surveillance and monitoring, prevalence, exposure to secondhand smoke, school-based tobacco control, cessation, media and advertising, and minor's access and availability). The synergy between the WHO FCTC, National Tobacco Control Action Plans, and GYTS offers countries a unique opportunity to develop, implement, and evaluate their comprehensive tobacco control programs. The reports included in this publication from Peru, Thailand, and Turkey are presented as examples of 'linking' GYTS data to the national tobacco control program efforts in each country.

Linking data to tobacco control program action among students aged 13–15 in Association of Southeast Asian Nations (ASEAN) member states, 2000–2006

Background:The Association of Southeast Asian Nations (ASEAN) has made tobacco use prevention a primary health issue. All ASEAN countries except Indonesia have ratified the World Health Organization Framework Convention on...