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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

Chow CK 1 , Corsi DJ 1 , Gilmore AB 2 , Kruger A 3 , Igumbor E 4 , Chifamba J 5 Show all authors , Yang W 6 , Wei L 7 , Iqbal R 8 , Mony P 9 , Gupta R 10 , Vijayakumar K 11 , Mohan V 12 , Kumar R 13 , Rahman O 14 , Yusoff K 15 , Ismail N 16 , Zatonska K 17 , Altuntas Y 18 , Rosengren A 19 , Bahonar A 20 , Yusufali A 21 , Dagenais G 22 , Lear S 23 , Diaz R 24 , Avezum A 25 , Lopez-Jaramillo P 26 , Lanas F 27 , Rangarajan S 28 , Teo K 28 , McKee M 29 , Yusuf S 28

Affiliations 

  • 1 Department of Cardiology, Westmead Hospital and The George Institute, University of Sydney, Camperdown, New South Wales, Australia
  • 2 Tobacco Control Research Group, Department for Health, University of Bath, Bath, UK
  • 3 Faculty of Health Science North, West University Potchefstroom Campus, Potchefstroom, South Africa
  • 4 School of Public Health, University of the Western Cape, Bellville, South Africa
  • 5 Physiology Department, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
  • 6 National Center for Cardiovascular Diseases, Beijing, China
  • 7 National Center for Cardiovascular Diseases Cardiovascular Institute & Fuwai Hospital Chinese Academy of Medical Sciences, Beijing, China
  • 8 Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
  • 9 Division of Epidemiology & Population Health, St John's Medical College & Research Institute, Bangalore, Karnataka, India
  • 10 Fortis Escorts Hospital, Jaipur, Rajasthan, India
  • 11 Department of Community Medicine, Dr Somervell Memorial CSI Medical College, Karakonam, Thiruvananthapuram, Kerala, India
  • 12 Madras Diabetes Research Foundation, Chennai, India
  • 13 PGIMER School of Public Health, Chandigarh, India
  • 14 Independent University, Bangladesh Bashundhara, Dhaka, Bangladesh
  • 15 Universiti Teknologi MARA Sungai Buloh, Selangor, Malaysia UCSI University, Cheras, Malaysia
  • 16 Department of Community Health, University Kebangsaan Malaysia Medical Centre, Bangi, Malaysia
  • 17 Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
  • 18 Sisli Etfal Teaching and Research Hospital, Istanbul, Turkey
  • 19 Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
  • 20 Hypertension Research Center Isfahan Cardiovascular Research Center Isfahan University of Medical Sciences, Isfahan, Iran
  • 21 Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
  • 22 Institut universitaire de cardiologie et pneumologie de Québec, Université laval,Quebec, Quebec, Montreal, Canada
  • 23 Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
  • 24 Estudios Clinicos Latinoamerica ECLA, Rosario, Argentina
  • 25 Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
  • 26 Fundacion Oftalmologica de Santander (FOSCAL), Floridablanca-Santander, Colombia
  • 27 Universidad de La Frontera, Temuco, Chile
  • 28 Population Health Research Institute(PHRI), Hamilton, Ontario, Canada
  • 29 London School of Hygiene and Tropical Medicine, London, UK
BMJ Open, 2017 03 31;7(3):e013817.
PMID: 28363924 DOI: 10.1136/bmjopen-2016-013817

Abstract

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.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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