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Smoking and tobacco
Research
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
  1. Clara K Chow1,2,
  2. Daniel J Corsi1,3,
  3. Anna B Gilmore4,
  4. Annamarie Kruger5,
  5. Ehimario Igumbor6,
  6. Jephat Chifamba7,
  7. Wang Yang8,
  8. Li Wei9,
  9. Romaina Iqbal10,
  10. Prem Mony11,
  11. Rajeev Gupta12,
  12. Krishnapillai Vijayakumar13,
  13. V Mohan14,
  14. Rajesh Kumar15,
  15. Omar Rahman16,
  16. Khalid Yusoff17,
  17. Noorhassim Ismail18,
  18. Katarzyna Zatonska19,
  19. Yuksel Altuntas20,
  20. Annika Rosengren21,
  21. Ahmad Bahonar22,
  22. AfzalHussein Yusufali23,
  23. Gilles Dagenais24,
  24. Scott Lear25,
  25. Rafael Diaz26,
  26. Alvaro Avezum27,
  27. Patricio Lopez-Jaramillo28,
  28. Fernando Lanas29,
  29. Sumathy Rangarajan2,
  30. Koon Teo2,
  31. Martin McKee30,
  32. Salim Yusuf2
  1. 1Department of Cardiology, Westmead Hospital and The George Institute, University of Sydney, Camperdown, New South Wales, Australia
  2. 2Population Health Research Institute(PHRI), Hamilton, Ontario, Canada
  3. 3Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  4. 4Tobacco Control Research Group, Department for Health, University of Bath, Bath, UK
  5. 5Faculty of Health Science North, West University Potchefstroom Campus, Potchefstroom, South Africa
  6. 6School of Public Health, University of the Western Cape, Bellville, South Africa
  7. 7Physiology Department, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
  8. 8National Center for Cardiovascular Diseases, Beijing, China
  9. 9National Center for Cardiovascular Diseases Cardiovascular Institute & Fuwai Hospital Chinese Academy of Medical Sciences, Beijing, China
  10. 10Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
  11. 11Division of Epidemiology & Population Health, St John's Medical College & Research Institute, Bangalore, Karnataka, India
  12. 12Fortis Escorts Hospital, Jaipur, Rajasthan, India
  13. 13Department of Community Medicine, Dr Somervell Memorial CSI Medical College, Karakonam, Thiruvananthapuram, Kerala, India
  14. 14Madras Diabetes Research Foundation, Chennai, India
  15. 15PGIMER School of Public Health, Chandigarh, India
  16. 16Independent University, Bangladesh Bashundhara, Dhaka, Bangladesh
  17. 17Universiti Teknologi MARA Sungai Buloh, Selangor, Malaysia UCSI University, Cheras, Malaysia
  18. 18Department of Community Health, University Kebangsaan Malaysia Medical Centre, Bangi, Malaysia
  19. 19Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
  20. 20Sisli Etfal Teaching and Research Hospital, Istanbul, Turkey
  21. 21Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
  22. 22Hypertension Research Center Isfahan Cardiovascular Research Center Isfahan University of Medical Sciences, Isfahan, Iran
  23. 23Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
  24. 24Institut universitaire de cardiologie et pneumologie de Québec, Université laval,Quebec, Quebec, Montreal, Canada
  25. 25Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
  26. 26Estudios Clinicos Latinoamerica ECLA, Rosario, Argentina
  27. 27Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
  28. 28Fundacion Oftalmologica de Santander (FOSCAL), Floridablanca-Santander, Colombia
  29. 29Universidad de La Frontera, Temuco, Chile
  30. 30London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to Professor Clara K Chow; cchow{at}georgeinstitute.org.au

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.

  • Tobacco environment
  • Tobacco control policy
  • Social unacceptability
  • Knowledge of tobacco harms

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjopen-2016-013817

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    Footnotes

    • Twitter Follow Ehimario Igumbor @Ehimario and Rajeev Gupta @rajeevgg

    • Contributors CC, DC, ABG, MK and SY contributed to the design and development of the study. CC drafted the paper, DC conducted all analyses, AG and MK contributed to the interpretation of the analyses. All other authors contributed to the data collection and implementation of the protocol. All authors reviewed and contributed to the manuscript draft and its revisions.

    • Funding The tobacco environment data collection and analyses was supported by a CIHR (Canadian Institute of Health Research) grant application number 184349. CC is supported by a NHMRC Career Development Award APP1033478 cofunded by the Heart Foundation and a Sydney Medical Foundation Chapmen Fellowship and a member of the cardiovascular group at the George Institute supported by a NHMRC programme grant. AG is a member of the UK Centre for Tobacco and Alcohol Studies (UKCTAS), a UK Centre for Public Health Excellence which is supported by the British Heart Foundation, Cancer Research UK, the Economic and Social Research Council, the Medical Research Council and the National Institute of Health Research, under the auspices of the UK Clinical Research Collaboration. EI is supported in part by the National Research Foundation of South Africa (UID: 86003). SY is supported by the Heart and Stroke Foundation Mary Burke Chair for CV research. The funders played no role in the study design, analysis and interpretation of data, nor writing of the report or the decision to submit the article for publication. The content is solely the responsibility of the authors and does not necessarily represent the views of the funders.

    • We have listed in a separate appendix the details of funding for the parent study PURE.

    • Competing interests None declared.

    • Ethics approval The EPOCH study and data collection instruments were approved by the Hamilton Health Sciences/McMaster Health Sciences Research Ethics board and by corresponding ethics boards in each country

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Data for this study and related studies from the PURE and EPOCH studies are stored at the Population Health Research Institute (PHRI), McMaster University. Requests for PURE and EPOCH data is assessed by the study steering committee and applications can be made to the study project manager, Sumathy Rangarajan sumathy.rangarajan@phri.ca.