Trends in cause-specific mortality among children aged 5-14 years from 2005 to 2016 in India, China, Brazil, and Mexico: an analysis of nationally representative mortality studies

BACKGROUND

With global survival increasing for children younger than 5 years of age, attention is required to reduce the approximately 1 million deaths of children aged 5-14 years occurring every year. Causes of death at these ages remain poorly documented. We aimed to explore trends in mortality by causes of death in India, China, Brazil, and Mexico, which are home to about 40% of the world's children aged 5-14 years and experience more than 200 000 deaths annually at these ages.

METHODS

We examined data on 244 401 deaths in children aged 5-14 years from four nationally representative data sources that obtained direct distributions of causes of death: the Indian Million Death Study, the Chinese Disease Surveillance Points, mortality data from the Mexican Instituto Nacional de Estadística y Geografía, and mortality data from the Brazilian Institute of Geography and Statistics. We present data on 12 main disease groups in all countries, with breakdown by communicable and nutritional diseases, non-communicable diseases, injuries, and ill-defined causes. To calculate age-specific and sex-specific death rates for each cause, we applied the national cause of death distribution to the UN mortality envelopes for 2005-16 for each country.

FINDINGS

Unlike Brazil, China, and Mexico, communicable diseases still account for nearly half of deaths in India in children aged 5-14 years (73 920 [46·1%] of 160 330 estimated deaths in 2016). In 2016, India had the highest death rates in nearly every category, including from communicable diseases. Fast declines among girls in communicable disease mortality narrowed the gap by 2016 with boys in India (32·6 deaths per 100 000 girls vs 26·2 per 100 000 boys) and China (1·7 vs 1·5). In China, injuries accounted for the greatest proportions of deaths (20 970 [53·2%] of 39 430 estimated deaths, in which drowning was a leading cause). The homicide death rate at ages 10-14 years was higher for boys than for girls in Brazil, increasing annually by an average of 0·7% (0·3-1·1). In India and China, the suicide death rates were higher for girls than for boys at ages 10-14 years. By contrast, in Mexico it was higher for boys than for girls, increasing annually by an average of 2·8% (2·0-3·6). Deaths from transport injuries, drowning, and cancer are common in all four countries, with transport accidents among the top three causes of death for both sexes in all countries, except for Indian girls, and cancer in the top three causes for both sexes in Mexico, Brazil, and China.

INTERPRETATION

Most of the deaths that occurred between 2005 and 2016 in children aged 5-14 years in India, China, Brazil, and Mexico arose from preventable or treatable conditions. This age group is important for extending some of the global disease-specific targets developed for children younger than 5 years of age. Interventions to control non-communicable diseases and injuries and to strengthen cause of death reporting systems are also required.

FUNDING

WHO and the University of Toronto Connaught Global Challenge.

[New tobacco products, a threat for tobacco control and public health of Mexico]

The new tobacco products that include electronic cigarettes (called "E Cig", "e-hookahs", "mods", "vape-pens"), electronic nicotine delivery systems (SEAN, Spanish acronym), similar systems without nicotine (SSSN, Spanish acronym) and alternative nicotine consumption systems (SACN, Spanish acronym), are positioned in the global market with a discourse of harm reduction and risk minimization. This manuscript summarizes the scientific evidence and presents a regulatory proposal for this technological innovation, oriented to guide the decision making of legislators, government institutions and organized civil society. The scientific evidence concludes that there is no safe tobacco product for health. The addictive nature of nicotine and the health damages for children, adolescents and pregnant women is the fundamental argument. These new products promote the transition to conventional cigarettes and have not shown efficacy for smoking cessation, on the contrary, they promote dual use. High-level regulation must be formulated without the intervention of the manufacturers or institutions with a conflict of interest in the context of the complete and integral World Health Organization Framework Convention on Tobacco Control implementation.

Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

Efforts to establish the 2015 baseline and monitor early implementation of the UN Sustainable Development Goals (SDGs) highlight both great potential for and threats to improving health by 2030. To fully deliver on the SDG aim of "leaving no one behind", it is increasingly important to examine the health-related SDGs beyond national-level estimates. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017), we measured progress on 41 of 52 health-related SDG indicators and estimated the health-related SDG index for 195 countries and territories for the period 1990-2017, projected indicators to 2030, and analysed global attainment.

METHODS

We measured progress on 41 health-related SDG indicators from 1990 to 2017, an increase of four indicators since GBD 2016 (new indicators were health worker density, sexual violence by non-intimate partners, population census status, and prevalence of physical and sexual violence [reported separately]). We also improved the measurement of several previously reported indicators. We constructed national-level estimates and, for a subset of health-related SDGs, examined indicator-level differences by sex and Socio-demographic Index (SDI) quintile. We also did subnational assessments of performance for selected countries. To construct the health-related SDG index, we transformed the value for each indicator on a scale of 0-100, with 0 as the 2·5th percentile and 100 as the 97·5th percentile of 1000 draws calculated from 1990 to 2030, and took the geometric mean of the scaled indicators by target. To generate projections through 2030, we used a forecasting framework that drew estimates from the broader GBD study and used weighted averages of indicator-specific and country-specific annualised rates of change from 1990 to 2017 to inform future estimates. We assessed attainment of indicators with defined targets in two ways: first, using mean values projected for 2030, and then using the probability of attainment in 2030 calculated from 1000 draws. We also did a global attainment analysis of the feasibility of attaining SDG targets on the basis of past trends. Using 2015 global averages of indicators with defined SDG targets, we calculated the global annualised rates of change required from 2015 to 2030 to meet these targets, and then identified in what percentiles the required global annualised rates of change fell in the distribution of country-level rates of change from 1990 to 2015. We took the mean of these global percentile values across indicators and applied the past rate of change at this mean global percentile to all health-related SDG indicators, irrespective of target definition, to estimate the equivalent 2030 global average value and percentage change from 2015 to 2030 for each indicator.

FINDINGS

The global median health-related SDG index in 2017 was 59·4 (IQR 35·4-67·3), ranging from a low of 11·6 (95% uncertainty interval 9·6-14·0) to a high of 84·9 (83·1-86·7). SDG index values in countries assessed at the subnational level varied substantially, particularly in China and India, although scores in Japan and the UK were more homogeneous. Indicators also varied by SDI quintile and sex, with males having worse outcomes than females for non-communicable disease (NCD) mortality, alcohol use, and smoking, among others. Most countries were projected to have a higher health-related SDG index in 2030 than in 2017, while country-level probabilities of attainment by 2030 varied widely by indicator. Under-5 mortality, neonatal mortality, maternal mortality ratio, and malaria indicators had the most countries with at least 95% probability of target attainment. Other indicators, including NCD mortality and suicide mortality, had no countries projected to meet corresponding SDG targets on the basis of projected mean values for 2030 but showed some probability of attainment by 2030. For some indicators, including child malnutrition, several infectious diseases, and most violence measures, the annualised rates of change required to meet SDG targets far exceeded the pace of progress achieved by any country in the recent past. We found that applying the mean global annualised rate of change to indicators without defined targets would equate to about 19% and 22% reductions in global smoking and alcohol consumption, respectively; a 47% decline in adolescent birth rates; and a more than 85% increase in health worker density per 1000 population by 2030.

INTERPRETATION

The GBD study offers a unique, robust platform for monitoring the health-related SDGs across demographic and geographic dimensions. Our findings underscore the importance of increased collection and analysis of disaggregated data and highlight where more deliberate design or targeting of interventions could accelerate progress in attaining the SDGs. Current projections show that many health-related SDG indicators, NCDs, NCD-related risks, and violence-related indicators will require a concerted shift away from what might have driven past gains-curative interventions in the case of NCDs-towards multisectoral, prevention-oriented policy action and investments to achieve SDG aims. Notably, several targets, if they are to be met by 2030, demand a pace of progress that no country has achieved in the recent past. The future is fundamentally uncertain, and no model can fully predict what breakthroughs or events might alter the course of the SDGs. What is clear is that our actions-or inaction-today will ultimately dictate how close the world, collectively, can get to leaving no one behind by 2030.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 comparative risk assessment (CRA) is a comprehensive approach to risk factor quantification that offers a useful tool for synthesising evidence on risks and risk-outcome associations. With each annual GBD study, we update the GBD CRA to incorporate improved methods, new risks and risk-outcome pairs, and new data on risk exposure levels and risk-outcome associations.

METHODS

We used the CRA framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or groups of risks from 1990 to 2017. This study included 476 risk-outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk and exposure estimates from 46 749 randomised controlled trials, cohort studies, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. We explored the relationship between development and risk exposure by modelling the relationship between the Socio-demographic Index (SDI) and risk-weighted exposure prevalence and estimated expected levels of exposure and risk-attributable burden by SDI. Finally, we explored temporal changes in risk-attributable DALYs by decomposing those changes into six main component drivers of change as follows: (1) population growth; (2) changes in population age structures; (3) changes in exposure to environmental and occupational risks; (4) changes in exposure to behavioural risks; (5) changes in exposure to metabolic risks; and (6) changes due to all other factors, approximated as the risk-deleted death and DALY rates, where the risk-deleted rate is the rate that would be observed had we reduced the exposure levels to the TMREL for all risk factors included in GBD 2017.

FINDINGS

In 2017, 34·1 million (95% uncertainty interval [UI] 33·3-35·0) deaths and 1·21 billion (1·14-1·28) DALYs were attributable to GBD risk factors. Globally, 61·0% (59·6-62·4) of deaths and 48·3% (46·3-50·2) of DALYs were attributed to the GBD 2017 risk factors. When ranked by risk-attributable DALYs, high systolic blood pressure (SBP) was the leading risk factor, accounting for 10·4 million (9·39-11·5) deaths and 218 million (198-237) DALYs, followed by smoking (7·10 million [6·83-7·37] deaths and 182 million [173-193] DALYs), high fasting plasma glucose (6·53 million [5·23-8·23] deaths and 171 million [144-201] DALYs), high body-mass index (BMI; 4·72 million [2·99-6·70] deaths and 148 million [98·6-202] DALYs), and short gestation for birthweight (1·43 million [1·36-1·51] deaths and 139 million [131-147] DALYs). In total, risk-attributable DALYs declined by 4·9% (3·3-6·5) between 2007 and 2017. In the absence of demographic changes (ie, population growth and ageing), changes in risk exposure and risk-deleted DALYs would have led to a 23·5% decline in DALYs during that period. Conversely, in the absence of changes in risk exposure and risk-deleted DALYs, demographic changes would have led to an 18·6% increase in DALYs during that period. The ratios of observed risk exposure levels to exposure levels expected based on SDI (O/E ratios) increased globally for unsafe drinking water and household air pollution between 1990 and 2017. This result suggests that development is occurring more rapidly than are changes in the underlying risk structure in a population. Conversely, nearly universal declines in O/E ratios for smoking and alcohol use indicate that, for a given SDI, exposure to these risks is declining. In 2017, the leading Level 4 risk factor for age-standardised DALY rates was high SBP in four super-regions: central Europe, eastern Europe, and central Asia; north Africa and Middle East; south Asia; and southeast Asia, east Asia, and Oceania. The leading risk factor in the high-income super-region was smoking, in Latin America and Caribbean was high BMI, and in sub-Saharan Africa was unsafe sex. O/E ratios for unsafe sex in sub-Saharan Africa were notably high, and those for alcohol use in north Africa and the Middle East were notably low.

INTERPRETATION

By quantifying levels and trends in exposures to risk factors and the resulting disease burden, this assessment offers insight into where past policy and programme efforts might have been successful and highlights current priorities for public health action. Decreases in behavioural, environmental, and occupational risks have largely offset the effects of population growth and ageing, in relation to trends in absolute burden. Conversely, the combination of increasing metabolic risks and population ageing will probably continue to drive the increasing trends in non-communicable diseases at the global level, which presents both a public health challenge and opportunity. We see considerable spatiotemporal heterogeneity in levels of risk exposure and risk-attributable burden. Although levels of development underlie some of this heterogeneity, O/E ratios show risks for which countries are overperforming or underperforming relative to their level of development. As such, these ratios provide a benchmarking tool to help to focus local decision making. Our findings reinforce the importance of both risk exposure monitoring and epidemiological research to assess causal connections between risks and health outcomes, and they highlight the usefulness of the GBD study in synthesising data to draw comprehensive and robust conclusions that help to inform good policy and strategic health planning.

FUNDING

Bill & Melinda Gates Foundation.

Patterns of awareness and use of electronic cigarettes in Mexico, a middle-income country that bans them: Results from a 2016 national survey

Among high-income countries, awareness and use of e-cigarettes is lower in countries with more restrictive e-cigarette regulations. Little is known about e-cigarettes in middle-income countries, many of which like Mexico, ban e-cigarette sales and marketing. The current study determined the national-level prevalence and correlates of e-cigarette awareness and consumption in Mexico. Data were analyzed from a 2016 nationally representative survey. Prevalence of e-cigarette awareness, trial and current use was estimated separately for adolescents (n = 12,436), adult nonsmokers (n = 36,966), and adult smokers (n = 7347). For each group, crude and adjusted logistic models regressed e-cigarette outcomes on sociodemographic and smoking-related variables, adjusting for the sampling design and weights. Prevalence varied across subgroups for e-cigarette awareness (adolescents = 45.3%; adult nonsmokers = 33.9%; adult smokers = 54.3%), e-cigarette trial (adolescents = 6.5%; adult nonsmokers = 2.6%; adult smokers = 18.2%) and current use of electronic cigarettes (adolescents = 1.1%; adult nonsmokers = 0.3%; adult smokers = 4.5%). Among adolescents and adults, current smoking and higher smoking frequency were significantly associated with e-cigarette awareness, trial and use. Among adolescents and nonsmokers, awareness, trial and use of e-cigarette were significantly lower among females than males. Among adult smokers, however, females were more likely to use e-cigarettes than males (AOR = 1.80; 95% CI = 1.08-3.02). Higher education and greater wealth increased the likelihood of trial of e-cigarettes among adult nonsmokers and smokers. Despite the ban on the distribution and sales of e-cigarettes, a substantial number of Mexicans, have access to e-cigarettes. Decision makers and advocates should consider e-cigarette regulations as recommended by the WHO, at the same time Mexico must invest in the infrastructure needed to enforce these regulations.

Concentrations of nicotine, nitrosamines, and humectants in legal and illegal cigarettes in Mexico

BACKGROUND

Article 10 of the World Health Organization Framework Convention on Tobacco Control states the need for industry disclosure of tobacco contents and emissions. Currently, the profiles of key tobacco compounds in legal and illegal cigarettes are largely unknown. We aimed to analyze and compare concentrations of nicotine, nitrosamines, and humectants in legal and illegal cigarettes collected from a representative sample of smokers.

METHODS

Participants of the International Tobacco Control cohort provided a cigarette pack of the brand they smoked during the 2014 wave. Brands were classified as legal or illegal according to the Mexican legislation. Nicotine, nitrosamines, glycerol, propylene glycol, and pH were quantified in seven randomly selected packs of each brand. All analyses were done blinded to legality status. Average concentrations per brand and global averages for legal and illegal brands were calculated. Comparisons between legal and illegal brands were conducted using t tests.

RESULTS

Participants provided 76 different brands, from which 6.8% were illegal. Legal brands had higher nicotine (15.05 ± 1.89 mg/g vs 12.09 ± 2.69 mg/g; p < 0001), glycerol (12.98 ± 8.03 vs 2.93 ± 1.96 mg/g; p < 0.001), and N-nitrosanatabine (NAT) (1087.5 ± 127.0 vs 738.5 ± 338 ng/g; p = 0.006) concentrations compared to illegal brands. For all other compounds, legal and illegal brands had similar concentrations.

CONCLUSION

Compared to illegal cigarettes, legal brands seem to have higher concentrations of nicotine, NAT, and glycerol. Efforts must be made to implement and enforce Article 10 of the Framework Convention on Tobacco Control to provide transparent information to consumers, regulators, and policy-makers; and to limit cigarette engineering from the tobacco industry.

"Vive Sin Tabaco… ¡Decídete!" Feasibility and Acceptability of an e-Health Smoking Cessation Informed Decision-Making Tool Integrated in Primary Healthcare in Mexico

Introduction: While smoking remains one of the leading causes of death in Mexico, uptake of evidence-based cessation therapy remains low. Widespread use of mobile devices and internet in Mexico has created new avenues for providing access to cessation treatment. Methods: We assessed the feasibility and acceptability of "Vive Sin Tabaco… ¡Decídete!" (English: Live without Tobacco…. Decide!), a web-based, informed decision-making tool designed to help Mexican smokers develop a quit plan and take advantage of cessation resources. We invited 164 smokers in two primary care clinics. Measures included physical, situational, and psychological nicotine dependence, interest in using pharmacotherapy and counseling, smoking status at 3 months, and satisfaction with the program. Results: Most participants were light smokers and reported low-to-moderate nicotine dependence. Immediately after using ¡Vive Sin Tabaco… ¡Decídete!, the majority were interested in quitting, set a quit date, and reported interest in using pharmacotherapy and cessation counseling. Follow-up rate at 3 months was 81.5%; seven-day point prevalence abstinence was 19.1% using intention-to-treat analysis. Conclusion: Integration of e-Health tools in primary healthcare settings has the potential to improve knowledge about cessation treatments among smokers and integrate smoking cessation into routine of care.

Smoking and prostate cancer: a life course analysis

Background

Inconsistent associations between smoking status and prostate cancer (PC) could be due to exposure assessment error. Reconstructing smoking behaviors over the life course could reduce exposure assessment error.

Methods

As part of a case-control study, we identified 402 incident and histologically confirmed PC cases that were matched by age (±5 years) to 805 population controls. Through direct interview, we obtained information about: age at smoking onset, intensity and frequency of cigarette smoking at different life stages, and smoking cessation age. Smoking status at interview and average smoking index over the lifetime (packs/year) were estimated. Life course smoking patterns were obtained applying the k-means+ method for longitudinal data to the smoking index (pack/year) for each life stage.

Results

Two life-course smoking patterns were identified among ever smokers: “pattern A” characterized by males who reported low and constant smoking intensity (87.8%), and “pattern B” (12.2%) males with an initial period of low intensity, followed by an increase during the second period. Compared to never smokers, pattern B was associated with higher poorly differentiated PC, (OR 2.30; 95% CI 1.21–4.38). No association was observed with average smoking index.

Conclusion

Life course smoking patterns seem to capture the smoking variability during life course and reduce the likelihood of reverse causation. Using this assessment strategy our findings support the potential role of tobacco smoking in PC, particularly poorly differentiated PC. Prospective studies with comprehensive smoking history during the lifetime are needed to confirm these findings.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4065-7) contains supplementary material, which is available to authorized users.

Divergence and convergence in cause-specific premature adult mortality in Mexico and US Mexican Hispanics from 1995 to 2015: analyses of 4.9 million individual deaths

Background

Mexicans and US Mexican Hispanics share modifiable determinants of premature mortality. We compared trends in mortality at ages 30-69 in Mexico and among US Mexican Hispanics from 1995 to 2015.

Methods

We examined nationally representative statistics on 4.2 million Mexican and 0.7 million US deaths to examine cause-specific mortality. We used lung cancer indexed methods to estimate smoking-attributable deaths stratified by high and lower burden Mexican states.

Results

In 1995-99, Mexican men had about 30% higher relative risk of death from all causes than US Mexican Hispanic men, and this difference nearly doubled to 58% by 2010-15. The divergence between Mexican and US Mexican Hispanic women over this time period was less marked. Among US Mexican Hispanics, declines in the risk of smoking-attributable death constituted about 25-30% of the declines in the overall risk of death. However, among Mexican men the declines in the risk of smoking-attributable deaths were offset by increases in causes of death not due to smoking. Homicide rates (mostly from guns) rose among men in Mexico from 2005 to 2010, but not among Mexican women or US Mexican Hispanic men or women. The probability at 30-69 years of death from cardiac disease diverged significantly between Mexicans and US Mexican Hispanics, reaching 10% and 5% for men, and 7% and 2% for women, respectively.

Conclusions

Large differences in premature mortality between otherwise genetically and culturally similar groups arise from a few modifiable factors, most notably smoking, untreated diabetes and homicide.

Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of risk factor exposure and attributable burden of disease. By providing estimates over a long time series, this study can monitor risk exposure trends critical to health surveillance and inform policy debates on the importance of addressing risks in context.

METHODS

We used the comparative risk assessment framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2016. This study included 481 risk-outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk (RR) and exposure estimates from 22 717 randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources, according to the GBD 2016 source counting methods. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. Finally, we explored four drivers of trends in attributable burden: population growth, population ageing, trends in risk exposure, and all other factors combined.

FINDINGS

Since 1990, exposure increased significantly for 30 risks, did not change significantly for four risks, and decreased significantly for 31 risks. Among risks that are leading causes of burden of disease, child growth failure and household air pollution showed the most significant declines, while metabolic risks, such as body-mass index and high fasting plasma glucose, showed significant increases. In 2016, at Level 3 of the hierarchy, the three leading risk factors in terms of attributable DALYs at the global level for men were smoking (124·1 million DALYs [95% UI 111·2 million to 137·0 million]), high systolic blood pressure (122·2 million DALYs [110·3 million to 133·3 million], and low birthweight and short gestation (83·0 million DALYs [78·3 million to 87·7 million]), and for women, were high systolic blood pressure (89·9 million DALYs [80·9 million to 98·2 million]), high body-mass index (64·8 million DALYs [44·4 million to 87·6 million]), and high fasting plasma glucose (63·8 million DALYs [53·2 million to 76·3 million]). In 2016 in 113 countries, the leading risk factor in terms of attributable DALYs was a metabolic risk factor. Smoking remained among the leading five risk factors for DALYs for 109 countries, while low birthweight and short gestation was the leading risk factor for DALYs in 38 countries, particularly in sub-Saharan Africa and South Asia. In terms of important drivers of change in trends of burden attributable to risk factors, between 2006 and 2016 exposure to risks explains an 9·3% (6·9-11·6) decline in deaths and a 10·8% (8·3-13·1) decrease in DALYs at the global level, while population ageing accounts for 14·9% (12·7-17·5) of deaths and 6·2% (3·9-8·7) of DALYs, and population growth for 12·4% (10·1-14·9) of deaths and 12·4% (10·1-14·9) of DALYs. The largest contribution of trends in risk exposure to disease burden is seen between ages 1 year and 4 years, where a decline of 27·3% (24·9-29·7) of the change in DALYs between 2006 and 2016 can be attributed to declines in exposure to risks.

INTERPRETATION

Increasingly detailed understanding of the trends in risk exposure and the RRs for each risk-outcome pair provide insights into both the magnitude of health loss attributable to risks and how modification of risk exposure has contributed to health trends. Metabolic risks warrant particular policy attention, due to their large contribution to global disease burden, increasing trends, and variable patterns across countries at the same level of development. GBD 2016 findings show that, while it has huge potential to improve health, risk modification has played a relatively small part in the past decade.

FUNDING

The Bill & Melinda Gates Foundation, Bloomberg Philanthropies.

Inter-rater reliability of measures to characterize the tobacco retail environment in Mexico

OBJECTIVE

To evaluate the inter-rater reliability of a data collection instrument to assess the tobacco retail environment in Mexico, after major marketing regulations were implemented.

MATERIALS AND METHODS

In 2013, two data collectors independently evaluated 21 stores in two census tracts, through a data collection instrument that assessed the presence of price promotions, whether single cigarettes were sold, the number of visible advertisements, the presence of signage prohibiting the sale of cigarettes to minors, and characteristics of cigarette pack displays. We evaluated the inter-rater reliability of the collected data, through the calculation of metrics such as intraclass correlation coefficient, percent agreement, Cohen's kappa and Krippendorff's alpha.

RESULTS

Most measures demonstrated substantial or perfect inter-rater reliability.

CONCLUSIONS

Our results indicate the potential utility of the data collection instrument for future point-of-sale research.

Fumar entre adolescentes: análisis cuantitativo y cualitativo de factores psicosociales asociados con la decisión de fumar en escolares mexicanos

Objetivo. Analizar factores psicosociales asociados con la decisión de fumar en estudiantes de entre 13 y 15 años de edad en la Ciudad de México. Material y métodos. Se utilizaron modelos de regresión logística de la Encuesta de Tabaquismo en Jóvenes (n=945) y cuatro grupos focales (GF) en dos escuelas secundarias, realizada en 2011 y 2012. Resultados. Factores asociados a fumar: a) creer que es seguro (RM=2.4, IC95% 1.28-4.7), GF: capacidad de control sobre consumo y daños a largo plazo; b) tener al menos un padre fumador (RM=1.6, IC95% 1.1-2.3), GF: influyen para iniciar/mantener consumo; c) tener amigos fumadores (RM=5.0, IC95% 1.9-13.6), GF: influyen para experimentación/ repetición, escuelas sin normas sobre prohibición y tener acceso a cigarros (RM=2.1, IC95% 0.9-4.1). Factores pro­tectores: a) creer que es dañino (RM=0.3, IC95% 0.14-0.65), GF: rechazo a convivencia con fumadores; b) comunicación con familia (RM=0.5, IC95% 0.36-0.91), GF: apelar al auto-cuidado; c) Considerarse joven para fumar (RM=0.2, IC95% 0.12-0.43), GF: conocimientos sobre daños y percepción de riesgo. Conclusión. Se deben fortalecer destrezas psicosociales positivas y el cumplimiento de legislación de protección a jóvenes.

Tabaquismo en Costa Rica: susceptibilidad, consumo y dependencia

Objetivo. Identificar elementos asociados con el taba­quismo, la susceptibilidad y la adicción en jóvenes de 13 a 15 años, para determinar condiciones de riesgo y posibles intervenciones desde las políticas sobre tabaco en Costa Rica. Material y métodos. Se utilizó información de las cuatro rondas de la Global Youth Tobacco Survey (GYTS) Costa Rica, con un tamaño muestral de 11 540 jóvenes colegiales. Se estimaron indicadores de interés y modelos de regresión logística para el consumo de tabaco, la susceptibilidad y la adicción. Resultados. La prevalencia de consumo actual dis­minuyó significativamente a lo largo de los 14 años del estudio (17.3% en 1999 y 5.0% en 2013) y también, aunque en menor intensidad, en el índice de susceptibilidad hacia el fumado (19.3% en 1999 y 12.4% en 2013). La proporción de jóvenes que presentan adicción ha mostrado un aumento importante en el mismo periodo. Conclusiones. Las condiciones que han favorecido la importante reducción en la prevalencia de consumo, y en menor medida de la susceptibilidad, deben mantenerse y profundizarse para lograr el cumplimiento pleno de las medidas del programa MPower.

[Financial impact of smoking on health systems in Latin America: A study of seven countries and extrapolation to the regional level]

OBJECTIVE

Estimate smoking-attributable direct medical costs in Latin American health systems.

METHODS

A microsimulation model was used to quantify financial impact of cardiovascular and cerebrovascular disease, chronic obstructive pulmonary disease (COPD), pneumonia, lung cancer, and nine other neoplasms. A systematic search for epidemiological data and event costs was carried out. The model was calibrated and validated for Argentina, Bolivia, Brazil, Chile, Colombia, Mexico, and Peru, countries that account for 78% of Latin America's population; the results were then extrapolated to the regional level.

RESULTS

Every year, smoking is responsible for 33 576 billion dollars in direct costs to health systems. This amounts to 0.7% of the region's gross domestic product (GDP) and 8.3% of its health budget. Cardiovascular disease, COPD, and cancer were responsible for 30.3%, 26.9%, and 23.7% of these expenditures, respectively. Smoking-attributable costs ranged from 0.4% (Mexico and Peru) to 0.9% (Chile) of GDP and from 5.2% (Brazil) to 12.7% (Bolivia) of health expenditures. In the region, tax revenues from cigarette sales barely cover 37% of smoking-attributable health expenditures (8.1% in Bolivia and 67.3% in Argentina).

CONCLUSIONS

Smoking is responsible for a significant proportion of health spending in Latin America, and tax revenues from cigarette sales are far from covering it. The region's countries should seriously consider stronger measures, such as an increase in tobacco taxes.

Tobacco and cancer: epidemiology and new perspectives of prevention and monitoring in Mexico

Tobacco smoking is causal risk factor of at least 16 different types of cancer. In Mexico, smoking causes 6 035 premature deaths annually of lung cancer and 5 154 from other types. Additionally, 16 408 new smoking- attributable cases are diagnosed, causing high costs in the Mexican health sector. The WHO Framework Convention on Tobacco Control is the global strategy to reduce morbidity and mortality caused by this risk factor. Four more cost-effective strategies to ensure the population benefit are: i) increase tobacco taxes, ii) create 100% smoke-free environments, iii) warn damage through health warnings with pictograms and iv) total ban of advertising and promotion. Mexico is call upon to implement with determination this comprehensive strategy to reduce cancer mortality and assuring the health population.

Cigarette brands with flavour capsules in the filter: trends in use and brand perceptions among smokers in the USA, Mexico and Australia, 2012-2014

OBJECTIVE

To describe trends, correlates of use and consumer perceptions related to the product design innovation of flavour capsules in cigarette filters.

METHODS

Quarterly surveys from 2012 to 2014 were analysed from an online consumer panel of adult smokers aged 18-64, living in the USA (n=6865 observations; 4154 individuals); Mexico (n=5723 observations; 3366 individuals); and Australia (n=5864 observations; 2710 individuals). Preferred brand varieties were classified by price (ie, premium; discount) and flavour (ie, regular; flavoured without capsule; flavoured with capsule). Participants reported their preferred brand variety's appeal (ie, satisfaction; stylishness), taste (ie, smoothness, intensity), and harm relative to other brands and varieties. GEE models were used to determine time trends and correlates of flavour capsule use, as well as associations between preferred brand characteristics (ie, price stratum, flavour) and perceptions of relative appeal, taste and harm.

RESULTS

Preference for flavour capsules increased significantly in Mexico (6% to 14%) and Australia (1% to 3%), but not in the USA (4% to 5%). 18-24 year olds were most likely to prefer capsules in the USA (10%) and Australia (4%), but not Mexico. When compared to smokers who preferred regular brands, smokers who preferred brands with capsules viewed their variety of cigarettes as having more positive appeal (all countries), better taste (all countries), and lesser risk (Mexico, USA) than other brand varieties.

CONCLUSIONS

Results indicate that use of cigarettes with flavour capsules is growing, is associated with misperceptions of relative harm, and differentiates brands in ways that justify regulatory action.

Mexico SimSmoke: how changes in tobacco control policies would impact smoking prevalence and smoking attributable deaths in Mexico

We examined the effect of tobacco control policies in Mexico on smoking prevalence and smoking-related deaths using the Mexico SimSmoke model. The model is based on the previously developed SimSmoke simulation model of tobacco control policy, and uses population size, smoking rates and tobacco control policy data for Mexico. It assesses, individually, and in combination, the effect of six tobacco control policies on smoking prevalence and smoking-related deaths. Policies included: cigarette excise taxes, smoke-free laws, anti-smoking public education campaigns, marketing restrictions, access to tobacco cessation treatments and enforcement against tobacco sales youth. The model estimates that, if Mexico were to adopt strong tobacco control policies compared to current policy levels, smoking prevalence could be reduced by 30% in the next decade and by 50% by 2053; an additional 470,000 smoking-related premature deaths could be averted over the next 40 years. The greatest impact on smoking and smoking-related deaths would be achieved by raising excise taxes on cigarettes from 55% to at least 70% of the retail price, followed by strong youth access enforcement and access to cessation treatments. Implementing tobacco control policies in Mexico could reduce smoking prevalence by 50%, and prevent 470,000 smoking-related deaths by 2053.

Evaluating the validity of self-reported smoking in Mexican adolescents

OBJECTIVES

We aimed to evaluate the validity of the self-reported smoking indicator used in the Global Youth Tobacco Survey (GYTS).

SETTING

43 middle and high-school classrooms from 26 schools were selected from Mexico City and Cuernavaca, Morelos.

PARTICIPANTS

A total of 1257 students provided both a questionnaire and a urine sample.

PRIMARY AND SECONDARY OUTCOME

Sensitivity and specificity of self-reported smoking compared to urinary cotinine. Validity indices were evaluated by subgroups of gender, social acceptability of smoking (ie, smoking parents or friends) and smoking frequency.

RESULTS

Sensitivity and specificity for current smoking were 93.2% and 81.7%, respectively. Validity indices remained stable across gender. Parental smoking status moderated the validity of self-report, which had lower sensitivity in adolescents with non-smoking parents (86.7%) than in adolescents with smoking parents (96.6%). Sensitivity and specificity increased with smoking frequency.

CONCLUSIONS

This first validation study of self-reported current smoking used in the GYTS among Mexican adolescents suggests that self-reported smoking in the past 30 days is a valid and stable indicator of current smoking behaviour. This measure appears suitable for public health research and surveillance.

Effects of tobacco control policies on smoking prevalence and tobacco-attributable deaths in Mexico: the SimSmoke model

OBJECTIVE

To examine how policies adopted in Mexico in response to the Framework Convention on Tobacco Control affected smoking prevalence and smoking-attributable deaths.

METHODS

The SimSmoke simulation model of tobacco control policy is applied to Mexico. This discrete time, first-order Markov model uses data on population size, smoking rates and tobacco control policy for Mexico. It assesses, individually and jointly, the effects of seven types of policies: cigarette taxes, smoke-free air laws, mass media campaigns, advertising bans, warning labels, cessation treatment, and youth tobacco access policies.

RESULTS

The Mexico SimSmoke model estimates that smoking rates have been reduced by about 30% as a result of policies implemented since 2002, and that the number of smoking-attributable deaths will have been reduced by about 826 000 by 2053. Increases in cigarette prices are responsible for over 60% of the reductions, but health warnings, smoke-free air laws, marketing restrictions and cessation treatments also play important roles.

CONCLUSIONS

Mexico has shown steady progress towards reducing smoking prevalence in a short period of time, as have other Latin American countries, such as Brazil, Panama and Uruguay. Tobacco control policies play an important role in continued efforts to reduce tobacco use and associated deaths in Mexico.

Medical care costs incurred by patients with smoking-related non-small cell lung cancer treated at the National Cancer Institute of Mexico

BACKGROUND

Smoking is a public health problem in Mexico and worldwide; its economic impact on developing countries has not been well documented. The aim of this study was to assess the direct medical costs attributable to smoking incurred by lung cancer patients treated at the National Cancer Institute of Mexico (INCan).

METHODS

The study was conducted at INCan in 2009. We carried out a cost of illness (COI) methodology, using data derived from an expert panel consensus and from medical chart review. A panel of experts developed a diagnostic-therapeutic guide that combined the hospital patient pathways and the infrastructure, human resources, technology, and services provided by the medical units at INCan. Cost estimates in Mexican pesos were adjusted by inflation and converted into US Dollars using the 2013 FIX exchange rate for foreign transactions (1 USD = 13.06 Mexican pesos).

RESULTS

A 297 incident cases diagnosed with any type of lung cancer were analyzed. According to clinical stage, the costs per patient were 13,456; 35,648; 106,186; and 144,555 USD, for lung cancer stages I, II, III, and IV respectively. The weighted average annual cost/patient was and 139,801 USD and the average annual cost/patient that was attributable to smoking was 92,269 USD. This cost was independent of the clinical stage, with stage IV representing 96% of the annual cost. The total annual cost of smoking-related lung cancer at INCan was 19,969,781 USD.

CONCLUSIONS

The medical care costs of lung cancer attributable to smoking represent a high cost both for INCan and the Mexican health sector. These costs could be reduced if all provisions established in the Framework Convention of Tobacco Control of the World Health Organization were implemented in Mexico.

Increasing availability and consumption of single cigarettes: trends and implications for smoking cessation from the ITC Mexico Survey

OBJECTIVE

Determine (1) trends in single cigarette availability and purchasing in Mexico and (2) the association between neighbourhood access to singles and cessation behaviour among adult Mexican smokers.

METHODS

We analysed data from Wave 4 (2010), Wave 5 (2011) and Wave 6 (2012) of the Mexican International Tobacco Control Policy Evaluation Survey. We used data from all three waves to examine time trends in singles availability and purchasing. To explore the association between neighbourhood access to singles and cessation behaviour, we used data from participants who were smokers at Wave 5 and followed up at Wave 6 (n=1272).

FINDINGS

The percentage of participants who saw singles sold daily (45.2% in 2010; 51.4% in 2011; 64.9% in 2012), who bought singles at least once a week (22.3% in 2010; 29.1% in 2011; 29.1% in 2012) and whose last cigarette purchase was a single (16.6% in 2010; 20.7% in 2011; 25.8% in 2012) increased significantly from 2010 to 2012 (all p<0.001). The average percentage of residents who reported seeing singles sold daily in their neighbourhood in 2012 was 60% (SD=25%). In adjusted analyses, smokers living in neighbourhoods with higher access to singles were less likely to make a quit attempt (risk ratio (RR)=0.72; 95% CI 0.46 to 1.12), and more likely to relapse (RR=1.30; CI 0.94 to 1.82), but these results were not statistically significant.

CONCLUSIONS

Single cigarettes appear widely accessible in Mexico and growing in availability. Future research should explore potential explanations, consequences and effective methods for reducing the availability of single cigarettes.

Neighbourhood deprivation and smoking and quit behaviour among smokers in Mexico: findings from the ITC Mexico Survey

BACKGROUND

In high-income countries (HICs), higher neighbourhood socioeconomic deprivation is associated with higher levels of smoking. Few studies in low-income and middle-income countries (LMICs) have investigated the role of the neighbourhood environment on smoking behaviour.

OBJECTIVE

To determine whether neighbourhood socioeconomic deprivation is related to smoking intensity, quit attempts, quit success and smoking relapse among a cohort of smokers in Mexico from 2010 to 2012.

METHODS

Data were analysed from adult smokers and recent ex-smokers who participated in waves 4-6 of the International Tobacco Control (ITC) Mexico Survey. Data were linked to the Mexican government's composite index of neighbourhood socioeconomic deprivation, which is based on 2010 Mexican Census data. We used generalised estimating equations to determine associations between neighbourhood deprivation and individual smoking behaviours.

FINDINGS

Contrary to past findings in HICs, higher neighbourhood socioeconomic deprivation was associated with lower smoking intensity. Quit attempts showed a U-shaped pattern whereby smokers living in high/very high deprivation neighbourhoods and smokers living in very low deprivation neighbourhoods were more likely to make a quit attempt than smokers living in other neighbourhoods. We did not find significant differences in neighbourhood deprivation on relapse or successful quitting, with the possible exception of people living in medium-deprivation neighbourhoods having a higher likelihood of successful quitting than people living in very low deprivation neighbourhoods (p=0.06).

CONCLUSIONS

Neighbourhood socioeconomic environments in Mexico appear to operate in an opposing manner to those in HICs. Further research should investigate whether rapid implementation of strong tobacco control policies in LMICs, as occurred in Mexico during the follow-up period, avoids the concentration of tobacco-related disparities among socioeconomically disadvantaged groups.

Impact of cigarette smoking on rates and clinical prognosis of pulmonary tuberculosis in Southern Mexico

OBJECTIVES

To examine the relationship between cigarette smoking and incidence and mortality rates of pulmonary tuberculosis (TB) and treatment outcomes.

MATERIALS

From 1995 to 2010, we analyzed data from 1062 patients with TB and from 2001 to 2004, 2951 contacts in Southern Mexico. Patients with acid-fast bacilli or Mycobacterium tuberculosis in sputum samples underwent epidemiological, clinical and mycobacteriological evaluation and received treatment by the local DOTS program.

RESULTS

Consumers of 1-10 (LS) or 11 or more (HS) cigarettes per day incidence (1.75 and 11.79) and mortality (HS, 17.74) smoker-non-smoker rate ratios were significantly higher for smokers. Smoker population was more likely to experience unfavorable treatment outcomes (HS, adjusted OR 2.36) and retreatment (LS and HS, adjusted hazard ratio (HR) 2.14 and 2.37). Contacts that smoked had a higher probability of developing active TB (HR 2.38) during follow up.

CONCLUSIONS

Results indicate the need of incorporating smoking prevention and cessation, especially among men, into international TB control strategies.