Tobacco control environment: cross-sectional survey of policy implementation, social unacceptability, knowledge of tobacco health harms and relationship to quit ratio in 17 low-income, middle-income and high-income countries
Annika Rosengren,
Li Wei,
Khalid Yusoff,
Martin McKee,
Clara K Chow,
Rajeev Gupta,
Koon Teo,
Sumathy Rangarajan,
Patricio Lopez-Jaramillo,
Rafael Diaz,
Alvaro Avezum,
Fernando Lanas,
Noorhassim Ismail,
Romaina Iqbal,
Jephat Chifamba,
Gilles Dagenais,
Salim Yusuf,
Anna B Gilmore,
Scott Lear,
Wang Yang,
Omar Rahman,
Katarzyna Zatonska,
Prem Mony,
Rajesh Kumar,
Afzalhussein Yusufali,
Daniel J Corsi,
Ehimario Igumbor,
V Mohan,
Annamarie Kruger,
Krishnapillai Vijayakumar,
Yuksel Altuntas,
Ahmad Bahonar
Affiliations
Annika Rosengren
Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
Li Wei
Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas, USA
Khalid Yusoff
UiTM, Selayang, Selangor and UCSI University, Cheras, Kuala Lumpur, Malaysia
Martin McKee
professor of European public health
Clara K Chow
The University of Sydney, Sydney Medical School, Sydney, New South Wales, Australia
Rajeev Gupta
Medicine, Eternal Heart Care Centre and Research Institute, Jaipur, Rajasthan, India
Koon Teo
Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
Sumathy Rangarajan
Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
Patricio Lopez-Jaramillo
Masira Research Institute, Universidad de Santander, Bucaramanga, Colombia
Rafael Diaz
ECLA - Academic Research Organization, Rosario, Argentina
Alvaro Avezum
International Research Center, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
Fernando Lanas
30 Internal Medicine, Universidad de La Frontera, Temuco, Chile
Noorhassim Ismail
18Department of Community Health, University Kebangsaan Malaysia Medical Centre, Bangi, Malaysia
Romaina Iqbal
Department of Community Health Sciences, The Aga Khan University, Karachi, Pakistan
Jephat Chifamba
Department of Physiology, University of Zimbabwe, Harare, Zimbabwe
Gilles Dagenais
Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City, Ontario, Canada
Salim Yusuf
Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
Anna B Gilmore
1 Department of Health, University of Bath, Bath, UK
Scott Lear
8 Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
Wang Yang
Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
Omar Rahman
University of Liberal Arts Bangladesh, Dhaka, Bangladesh
Katarzyna Zatonska
Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
Prem Mony
1 Division of Epidemiology, Biostatistics & Population Health, St John`s Research Institute, St John`s Medical College, Bangalore, Karnataka, India
Rajesh Kumar
U.O. Rheumatology and Clinical immunology, ASST Spedali Civili of Brescia, Clinical and Experimental Sciences, BRESCIA, Italy
Afzalhussein Yusufali
professor
Daniel J Corsi
School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
Ehimario Igumbor
Prevention Programmes and Knowledge Management, Nigeria Centre for Disease Control, Abuja, Federal Capital Territory, Nigeria
V Mohan
Madras Diabetes Research Foundation, Chennai, India
Annamarie Kruger
5Faculty of Health Science North, West University Potchefstroom Campus, Potchefstroom, South Africa
Krishnapillai Vijayakumar
Community Medicine, Health Action by People, Thiruvananthapuram, Kerala, India
Yuksel Altuntas
professor
Ahmad Bahonar
Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (the Islamic Republic of)
Objectives This study examines in a cross-sectional study ‘the tobacco control environment’ including tobacco policy implementation and its association with quit ratio.Setting 545 communities from 17 high-income, upper-middle, low-middle and low-income countries (HIC, UMIC, LMIC, LIC) involved in the Environmental Profile of a Community's Health (EPOCH) study from 2009 to 2014.Participants Community audits and surveys of adults (35–70 years, n=12 953).Primary and secondary outcome measures Summary scores of tobacco policy implementation (cost and availability of cigarettes, tobacco advertising, antismoking signage), social unacceptability and knowledge were associated with quit ratios (former vs ever smokers) using multilevel logistic regression models.Results Average tobacco control policy score was greater in communities from HIC. Overall 56.1% (306/545) of communities had >2 outlets selling cigarettes and in 28.6% (154/539) there was access to cheap cigarettes (<5cents/cigarette) (3.2% (3/93) in HIC, 0% UMIC, 52.6% (90/171) LMIC and 40.4% (61/151) in LIC). Effective bans (no tobacco advertisements) were in 63.0% (341/541) of communities (81.7% HIC, 52.8% UMIC, 65.1% LMIC and 57.6% LIC). In 70.4% (379/538) of communities, >80% of participants disapproved youth smoking (95.7% HIC, 57.6% UMIC, 76.3% LMIC and 58.9% LIC). The average knowledge score was >80% in 48.4% of communities (94.6% HIC, 53.6% UMIC, 31.8% LMIC and 35.1% LIC). Summary scores of policy implementation, social unacceptability and knowledge were positively and significantly associated with quit ratio and the associations varied by gender, for example, communities in the highest quintile of the combined scores had 5.0 times the quit ratio in men (Odds ratio (OR) 5·0, 95% CI 3.4 to 7.4) and 4.1 times the quit ratio in women (OR 4.1, 95% CI 2.4 to 7.1).Conclusions This study suggests that more focus is needed on ensuring the tobacco control policy is actually implemented, particularly in LMICs. The gender-related differences in associations of policy, social unacceptability and knowledge suggest that different strategies to promoting quitting may need to be implemented in men compared to women.
