Estimates of global and regional smoking prevalence in 1995, by age and sex

Reducing the burden of smoking world-wide: effectiveness of interventions and their coverage

Cigarette smoking and other tobacco use imposes a huge and growing public health burden globally. Currently, approximately 5 million people are killed annually by tobacco use; by 2030, estimates based on current trends indicate that this number will increase to 10 million, with 70% of deaths occurring in low- and middle-income countries. Numerous studies from high-income countries, and a growing number from low- and middle-income countries, provide strong evidence that tobacco tax increases, dissemination of information about health risks from smoking, restrictions on smoking in public places and in work-places, comprehensive bans on advertising and promotion and increased access to cessation therapies are all effective in reducing tobacco use and its consequences. Despite this evidence, tobacco control policies have been unevenly applied--due partly to political constraints. This paper provides a summary of these issues, beginning with an overview of trends in global tobacco use and its consequences and followed by a review of the evidence on the effectiveness of tobacco control policies in reducing tobacco use. A description of the types and comprehensiveness of policies currently in place and a discussion of some of the factors correlated with the strength and comprehensive of these policies follows.

Ideal self-image congruency as a motivator for smoking: the moderating effects of personality traits

A content analysis showed that cigarette advertising in Taiwan from June 2001 to May 2003 portrayed smokers as masculine, adventurous, pleasure-loving, and sociable. A survey of 1,490 high school students further indicated that smokers and nonsmokers differ in the congruency between their ideal self-images and the perceived smoker image on these 4 image dimensions. The self-smoker image congruency was greater for smokers than for nonsmokers and was positively associated with attitudes toward cigarette advertising Most important, this study demonstrated that participants' personality traits moderated self-smoker image congruency effects on smoking attitudes. Implications and suggestions for antismoking campaigns are discussed.

Biologic treatment of rheumatoid arthritis and the risk of malignancy: Analyses from a large US observational study

OBJECTIVE

Induction of malignancy is a major concern when rheumatoid arthritis (RA) is treated with biologic therapy. A meta-analysis of RA biologic clinical trials found a general increased risk of malignancy, but this risk was not found in a large observational study. We undertook this study to assess the risk of malignancy among biologic-treated patients in a large US observational database.

METHODS

We studied incident cases of cancer among 13,001 patients during approximately 49,000 patient-years of observation in the years 1998-2005. Cancer rates were compared with population rates using the US National Cancer Institute SEER (Surveillance, Epidemiology, and End-Results) database. Assessment of the risk of biologic therapy utilized conditional logistic regression to calculate odds ratios (ORs) as estimates of the relative risk, further adjusted for 6 confounders: age, sex, education level, smoking history, RA severity, and prednisone use.

RESULTS

Biologic exposure was 49%. There were 623 incident cases of nonmelanotic skin cancer and 537 other cancers. The standardized incidence ratios and 95% confidence intervals (95% CIs) compared with SEER data were as follows: all cancers 1.0 (1.0-1.1), breast 0.8 (0.6-0.9), colon 0.5 (0.4-0.6), lung 1.2 (1.0-1.4), lymphoma 1.7 (1.3-2.2). Biologics were associated with an increased risk of nonmelanotic skin cancer (OR 1.5, 95% CI 1.2-1.8) and melanoma (OR 2.3, 95% CI 0.9-5.4). No other malignancy was associated with biologic use; the OR (overall risk) of any cancer was 1.0 (95% CI 0.8-1.2).

CONCLUSION

Biologic therapy is associated with increased risk for skin cancers, but not for solid tumors or lymphoproliferative malignancies. These associations were consistent across different biologic therapies.

Changing smoking attitudes by strengthening weak antismoking beliefs - Taiwan as an example

I first explored the strength of Taiwanese high school students' beliefs regarding five antismoking messages. Findings of a nationwide survey showed that the students held these beliefs in the following order of decreasing strength: second-hand smoke damages health, smoking has long-term health consequences, smoking has short-term health consequences, cigarette marketers are manipulative, and smokers are perceived negatively. Experiment one further showed that antismoking ads featuring weakly held beliefs are more effective than those featuring strongly held beliefs. Experiment two demonstrated that antismoking campaigns need to be framed carefully; in general, it is more effective to positively frame messages about strongly held antismoking beliefs but negatively frame messages about weakly held antismoking beliefs.

Globalization and Tobacco

This chapter reviews the evolving economic and social system sustaining the growing tobacco epidemic in order to identify how globalization is affecting the industry, governments, and tobacco control advocates. It is divided into four main sections. The first section recalls key historical events that led to the worldwide prominence of tobacco use and the global rise of tobacco-related death and disease. The second section examines scientific evidence regarding the health effects of active and passive smoking and reviews the globalization of the public health response to the tobacco epidemic. The third section describes the Framework Convention on Tobacco Control (FCTC) negotiating process and final treaty text. The fourth section analyzes some of the remaining major challenges resulting from working within a global system, in particular, those challenges associated with developing coherent domestic and international policies and the permanent need to anticipate the unintended consequences of national and global regulations. The chapter concludes by identifying new directions and resources for global tobacco control and predicting some of the main challenges that lie ahead.

Why Do Women Have Back Pain More Than Men?

OBJECTIVES

In comparison with men, women have a healthier lifestyle, are more rarely overweight, have less stressful occupations, or are not employed outside the home. The "gender pain bias" is the fact that women nevertheless have a higher prevalence of back pain. This paper looks at the possible underlying reasons for this as yet unexplained gender difference, using Stokols' socioecological health model as a basis.

METHODS

The first National Health Survey for the Federal Republic of Germany was carried out from October 1997 to March 1999. It comprised a representative total sample of 5315 persons between the ages of 20 and 64. The participants took part in a medical examination and answered a self-report form. chi test and logistic regression analyses were used to investigate correlations between self-reported low back pain and gender-specific biopsychobehavioral and sociophysical environmental factors.

RESULTS

Seven-day back pain prevalence in the Federal Republic of Germany is 32% for men and 40% for women. Prevalences are significantly higher for overweight subjects, persons with a marked somatization tendency or a low level of social support, physically inactive individuals, smokers, elderly subjects, the nonemployed, "blue collar workers" and lower socioeconomic groups. From a multivariate perspective, however, none of these factors reduces (and hence sufficiently explains) the gender difference. Factoring in the gender-specific somatization tendency reduces the odds ratios of women versus men from 1.42 to 1.23.

DISCUSSION

In view of the gender difference in pain prevalence, which remains stable despite a multivariate perspective, there is clearly a need for more research into the reasons underlying the gender difference. We believe that future studies should look at rarely investigated constructs such as "sex role expectancies," "anxiety," "ethnicity," and "family history" and take anatomic differences in muscle strength into account.

Youth tobacco use: a global perspective for child health care clinicians

Tobacco dependence, responsible for approximately 4 million annual deaths worldwide, is considered to be a "pediatric disease." The smoking epidemic is spreading rapidly in developing countries. Factors contributing to youth smoking in developing countries include cultural traditions, tobacco's easy accessibility and moderate pricing, peer and family influences, and tobacco companies' advertisements and promotional activities. Secondhand tobacco smoke exposure is a substantial problem that causes increased rates of pneumonia, otitis media, asthma, and other short- and long-term pediatric conditions. Parental tobacco use results in children's deprivation of essential needs such as nutrition and education. In this article we review contemporary evidence with respect to the etiology of nicotine dependence among youth, the forms of youth tobacco products worldwide, global youth tobacco-control efforts to date, medical education efforts, and child health care clinicians' special role in youth tobacco-control strategies. In addition, we provide a review of currently available funding opportunities for development and implementation of youth tobacco-control programs.

Smoking patterns and predictors of smoking cessation in elderly populations in Lebanon

OBJECTIVE

To investigate smoking patterns in an elderly, low-income population and to identify predictors of smoking cessation, in addition to analyzing the importance of smoking in relation to other risk factors for hospitalization.

DESIGN

The data were part of an urban health study conducted among 740 individuals aged > or = 60 years in three suburban communities of low socio-economic status in Beirut, one of them a refugee camp. A detailed interview schedule was administered that included comprehensive social and health information.

RESULTS

The overall prevalence of current smokers was 28.1%. Almost half of the group were ever smokers, of whom 44% had quit smoking when they experienced negative health effects. Having at least one chronic illness and having a functional disability significantly increased the odds of smoking cessation. In addition, being a former smoker increased the likelihood of hospital admission.

CONCLUSIONS

This study is of particular importance, as it has implications for similar low-income and refugee communities in the region and elsewhere. There is a need for more concerted efforts by public health officials to target elderly individuals as a group for smoking cessation interventions, particularly now that mortality and health benefits have been well documented.

Tobacco consumption and its association with illicit drug use among men in Bangladesh

AIMS

This study examined the association of tobacco consumption (smoking and chewing) with illicit drug use among Bangladesh males.

DESIGN

Cross-sectional survey data from the Bangladesh Demographic and Health Survey 2004 were used.

SETTING

Bangladesh.

PARTICIPANTS

A total of 4297 males aged 15-54 years.

MEASUREMENTS

Age, education, religion, marital status, place of residence; tobacco consumption such as cigarette and bidi smoking, chewing sada, pata, tobacco leaves, gul, betel quid with zarda; taking illicit drugs such as ganja, charas, heroin, pethedine, phensidyl; having sexually transmitted diseases (STDs).

FINDINGS

Overall prevalence of tobacco consumption was 59%. Bidi smoking (29.6%), cigarette smoking (27.8%) and chewing betel quid with tobacco/zarda (17.5%) were predominant. Overall prevalence of illicit drug use was 4%. Ganja was the main drug (3%), followed by phensidyl (0.8%), heroin (0.3%) and charas (0.3%). Age, education, place of residence, marital status, having STDs, premarital and extra-marital sex were associated significantly with tobacco smoking. Almost all variables were also associated significantly with illicit drug use. Smoking cigarettes and bidi and eating tobacco leaves/shada pata/gul showed significantly positive associations with illicit drug use when adjusted for other variables.

CONCLUSIONS

Tobacco consumption is common and associated positively with the illicit drug use among males in Bangladesh.

Tobacco use in the Dominican Republic: understanding the culture first

OBJECTIVE

To conduct formative research on the landscape of tobacco use to guide survey and subsequent intervention development in the Dominican Republic (DR).

DESIGN

Rapid Assessment Procedures, systematic qualitative methods (participant-observations, in-depth interviewing, focus groups) using bilingual mixed age and gendered teams from the United States and DR.

SUBJECTS

Over 160 adults (men and women), ages 18 to 90 years, current, former and never smokers, community members and leaders from six underserved, economically disadvantaged DR communities.

MAIN OUTCOME MEASURES

Key domains: tobacco use patterns and attitudes; factors affecting smoking initiation, continuation, quitting; perceived risks/benefits/effects of smoking; and awareness/effects of advertising/regulations.

RESULTS

Perceptions of prevalence varied widely. While "everybody" smokes, smokers or ex-smokers were sometimes difficult to find. Knowledge of health risks was limited to the newly mandated statement "Fumar es prejudicial para la salud" [Smoking is harmful to your health]. Smokers started due to parents, peers, learned lifestyle, fashion or as something to do. Smoking served as an escape, relaxation or diversion. Quit attempts relied on personal will, primarily for religious or medical reasons. Social smoking (custom or habit) (< 10 cigarettes per day) was viewed as a lifestyle choice rather than a vice or addiction. Out of respect, smokers selected where they smoked and around whom. Health care providers typically were reactive relative to tobacco cessation, focusing on individuals with smoking related conditions. Tobacco advertising was virtually ubiquitous. Anti-tobacco messages were effectively absent. Cultures of smoking and not smoking coexisted absent a culture of quitting.

CONCLUSIONS

Systematic qualitative methods provided pertinent information about tobacco attitudes and use to guide subsequent project steps. Integrating qualitative then quantitative research can be replicated in similar countries that lack empirical data on the cultural dimensions of tobacco use.

Smoking cessation counseling by Russian oncologists: opportunities for intervention in the Russian Federation

The goal of this study was to examine the degree to which Russian oncologists are trained in providing smoking cessation counseling to patients and to assess physician smoking cessation practices and attitudes about providing smoking cessation treatment. Sixty-three oncologists at a large cancer center in Moscow completed a brief survey. The results showed that Russian oncologists: (a) lack training in smoking interventions; (b) rarely offer cessation treatment; (c) exhibit beliefs about smoking that may serve as barriers to providing cessation counseling; and (d) desire training in cessation counseling. These results can be used to guide the development of smoking cessation training programs for Russian physicians.

Does smoking explain sex differences in the global tuberculosis epidemic?

To date there has been no satisfactory explanation of the worldwide excess of tuberculosis (TB) notifications among adult males. We investigated the epidemiological basis for sex differences in TB notifications in high-burden countries using available group-level data. Multiple linear regression analysis was used to explore the ecological relationship between smoking and sex differences in TB notifications among high-burden countries. Cigarette consumption was a significant predictor of the sex ratio of TB notifications, and explained 33% of the variance in the sex ratio of TB notifications. Our findings suggest that smoking is an important modifiable factor which has a significant impact on the global epidemiology of TB, and emphasize the importance of tobacco control in countries with a high incidence of TB. This analysis provides support for the interpretation of sex differences in worldwide TB notification rates as indicative of true differences in the epidemiology of TB between males and females.

Role of smoking in global and regional cancer epidemiology: current patterns and data needs

Although smoking is widely recognized as a major cause of cancer, there is little information on how it contributes to the global and regional burden of cancers in combination with other risk factors that affect background cancer mortality patterns. We used data from the American Cancer Society's Cancer Prevention Study II (CPS-II) and the WHO and IARC cancer mortality databases to estimate deaths from 8 clusters of site-specific cancers caused by smoking, for 14 epidemiologic subregions of the world, by age and sex. We used lung cancer mortality as an indirect marker for accumulated smoking hazard. CPS-II hazards were adjusted for important covariates. In the year 2000, an estimated 1.42 (95% CI 1.27-1.57) million cancer deaths in the world, 21% of total global cancer deaths, were caused by smoking. Of these, 1.18 million deaths were among men and 0.24 million among women; 625,000 (95% CI 485,000-749,000) smoking-caused cancer deaths occurred in the developing world and 794,000 (95% CI 749,000-840,000) in industrialized regions. Lung cancer accounted for 60% of smoking-attributable cancer mortality, followed by cancers of the upper aerodigestive tract (20%). Based on available data, more than one in every 5 cancer deaths in the world in the year 2000 were caused by smoking, making it possibly the single largest preventable cause of cancer mortality. There was significant variability across regions in the role of smoking as a cause of the different site-specific cancers. This variability illustrates the importance of coupling research and surveillance of smoking with that for other risk factors for more effective cancer prevention.

Personal values, advertising, and smoking motivation in Taiwanese adolescents

This article explores the role that personal values plays in motivating Taiwanese adolescents to smoke. In a nationwide survey of high school students, smokers attached greater importance to hedonic gratification values and less importance to idealism values than did nonsmokers. Hedonic gratification values were associated with favorable attitudes toward smoking, while idealism values were associated with unfavorable attitudes toward smoking. Attitudes toward smoking predicted adolescent smoking behavior. Evidence suggested that advertising plays an important role in motivating adolescents with hedonic gratification values to smoke. First, in the survey, hedonic gratification values were associated with paying attention to and expressing favorable attitudes toward cigarette advertising. Second, a content analysis of cigarette ads in magazines found hedonic gratification values to be the most commonly portrayed values, occurring in 62.7% of ads.

Role of Smoking in Global and Regional Cardiovascular Mortality

Background— Smoking is a major cause of cardiovascular disease mortality. There is little information on how it contributes to global and regional cause-specific mortality from cardiovascular diseases for which background risk varies because of other risks.

Method and Results— We used data from the American Cancer Society’s Cancer Prevention Study II (CPS II) and the World Health Organization Global Burden of Disease mortality database to estimate smoking-attributable deaths from ischemic heart disease, cerebrovascular disease, and a cluster of other cardiovascular diseases for 14 epidemiological subregions of the world by age and sex. We used lung cancer mortality as an indirect marker for accumulated smoking hazard. CPS-II hazards were adjusted for important covariates. In the year 2000, an estimated 1.62 (95% CI, 1.27 to 2.04) million cardiovascular deaths in the world, 11% of total global cardiovascular deaths, were due to smoking. Of these, 1.17 million deaths were among men and 450 000 among women. There were 670 000 (95% CI, 440 000 to 920 000) smoking-attributable cardiovascular deaths in the developing world and 960 000 (95% CI, 770 000 to 1 200 000) in industrialized regions. Ischemic heart disease accounted for 54% of smoking-attributable cardiovascular mortality, followed by cerebrovascular disease (25%). There was variability across regions in the role of smoking as a cause of various cardiovascular diseases.

Conclusions— More than 1 in every 10 cardiovascular deaths in the world in the year 2000 were attributable to smoking, demonstrating that it is an important preventable cause of cardiovascular mortality.

Patterns of tobacco use in the early epidemic stages: Malawi and Zambia, 2000-2002

OBJECTIVES

I examined demographic and socioeconomic patterns of tobacco use in 2 African nations in the early stages of epidemic.

METHODS

I used population-based data from the Demographic Health Surveys of men aged 15-59 years (N=5111) and women aged 15-49 years (N=20809) in Malawi (2000) and Zambia (2001/2002) and multinomial logistic regression models to examine tobacco use (nonsmoker, light cigarette smoker, heavy cigarette smoker, and user of other tobacco) as a function of age, residence, education, occupation, marital status, and religion.

RESULTS

Male tobacco users tend to be less educated, urban, household service or manual workers, formerly married, and non-Christian and non-Muslim. Although tobacco use is less common among women, it relates inversely to their education and occupational status. Tobacco users more often reported drinking, getting drunk, and, among men, paying for sex.

CONCLUSIONS

Tobacco use patterns in 2 African nations at the early stages of epidemic suggest the need for public health officials to focus on disadvantaged groups to prevent the worldwide spread of tobacco.

Calculation of population attributable risk for bidi smoking and oral cancer in south Asia

BACKGROUND

Bidi smoking, which is widely prevalent in India and in other south Asian countries, increases the risk of oral cancer as observed in case-control studies and metaanalysis. However, population attributable risk percent (PAR%) has not been determined yet.

MATERIALS AND METHODS

Twelve case-control studies conducted in India, Pakistan, and Sri Lanka, which included information on bidi smoking and oral cancer, were analyzed countrywise to estimate PAR%.

RESULTS

The cumulative cases and controls were 4778 and 6271, respectively, based on 10 case-control studies conducted in India. Among the cases, 49.1% were bidi smokers and 7.7% cigarette smokers, while they were 19.9% and 10.3%, respectively, among controls. Pooled odds ratio (OR) of bidi smoking for oral cancer was 3.3 [95% confidence interval (CI), 3.0-3.6] and 2.6 (95% CI 1.8-3.8), respectively, based on fixed- and random-effects model. Cigarette smoking, on the other hand, did not show any significant association. PAR% of bidi smoking for oral cancer ranged from 4.7% to 51.6% on individual study basis, while they were 31.4% and 24.1%, respectively, based on OR derived from fixed- and random-effects models. PAR% was 5.8% and 8.7% based on single study estimate from Pakistan and Sri Lanka, respectively.

CONCLUSIONS

Bidi smoking is considered to account for a sizeable number of oral cancers in south Asian countries, which implies that cessation programs should be formulated and implemented vigorously.

Rethinking the "diseases of affluence" paradigm: global patterns of nutritional risks in relation to economic development

BACKGROUND

Cardiovascular diseases and their nutritional risk factors--including overweight and obesity, elevated blood pressure, and cholesterol--are among the leading causes of global mortality and morbidity, and have been predicted to rise with economic development.

METHODS AND FINDINGS

We examined age-standardized mean population levels of body mass index (BMI), systolic blood pressure, and total cholesterol in relation to national income, food share of household expenditure, and urbanization in a cross-country analysis. Data were from a total of over 100 countries and were obtained from systematic reviews of published literature, and from national and international health agencies. BMI and cholesterol increased rapidly in relation to national income, then flattened, and eventually declined. BMI increased most rapidly until an income of about ID 5,000 (international dollars) and peaked at about ID 12,500 for females and ID 17,000 for males. Cholesterol's point of inflection and peak were at higher income levels than those of BMI (about ID 8,000 and ID 18,000, respectively). There was an inverse relationship between BMI/cholesterol and the food share of household expenditure, and a positive relationship with proportion of population in urban areas. Mean population blood pressure was not correlated or only weakly correlated with the economic factors considered, or with cholesterol and BMI.

CONCLUSIONS

When considered together with evidence on shifts in income-risk relationships within developed countries, the results indicate that cardiovascular disease risks are expected to systematically shift to low-income and middle-income countries and, together with the persistent burden of infectious diseases, further increase global health inequalities. Preventing obesity should be a priority from early stages of economic development, accompanied by population-level and personal interventions for blood pressure and cholesterol.

Training nurses and social workers in smoking cessation counseling: a population needs assessment in Hong Kong

BACKGROUND

To achieve greater coverage of elderly smokers and to shift entire populations toward cessation, the provider-client interface could be broadened beyond physicians to include nurses and social workers, who can be formally trained to provide such services. We carried out a population-based training needs assessment of the latter two groups in Hong Kong.

METHODS

Three thousand seven hundred eligible hospital-based nurses and 2,258 social workers who had elderly clients in Hong Kong were recruited in a knowledge, attitude, and practice (KAP) cross-sectional survey. We used multivariable logistic regression to identify predictors for two key outcomes-"initiation and advice" (ask and advise) and "follow-through" (assess, assist and arrange), based on the U.S. Agency for Health Care Policy Research framework.

RESULTS

One thousand eight hundred forty-three (49.8%) nurses and 1,499 (66.4%) social workers responded. Nurses reported a much higher level of engagement in smoking cessation activities than social workers in all five steps of the AHCPR framework (P<0.001). Nurses (mean score=2.99+/-0.40 on a 4-point Likert scale) had more positive attitudes to tobacco control and smoking cessation counseling compared to social workers (mean score=2.79+/-0.41; P<0.001), whereas the latter group perceived themselves as more competent in handling such practice (mean score(nurses)=2.36+/-0.52, mean score(social workers)=2.51+/-0.39; P<0.001). Both attitudinal and self-perceived competence scores predicted incremental gains in the likelihood of offering "follow-through" interventions in addition to those observed for "initiation and advice" actions.

CONCLUSION

Our findings highlight a large degree of unmet need in Hong Kong's hospital-based nurses and social workers who work with the elderly regarding smoking cessation service provision and training. Future research should focus on developing and evaluating programs that encourage nurses and social workers to provide cessation interventions to exert a much greater collective impact than doctors can alone.

Regular use of alcohol and tobacco in India and its association with age, gender, and poverty

This study provides national estimates of regular tobacco and alcohol use in India and their associations with gender, age, and economic group obtained from a representative survey of 471,143 people over the age of 10 years in 1995-96, the National Sample Survey. The national prevalence of regular use of smoking tobacco is estimated to be 16.2%, chewing tobacco 14.0%, and alcohol 4.5%. Men were 25.5 times more likely than women to report regular smoking, 3.7 times more likely to regularly chew tobacco, and 9.7 times more likely to regularly use alcohol. Respondents belonging to scheduled castes and tribes (recognized disadvantaged groups) were significantly more likely to report regular use of alcohol as well as smoking and chewing tobacco. People from rural areas had higher rates compared to urban dwellers, as did those with no formal education. Individuals with incomes below the poverty line had higher relative odds of use of chewing tobacco and alcohol compared to those above the poverty line. The regular use of both tobacco and alcohol also increased significantly with each diminishing income quintile. Comparisons are made between these results and those found in the United States and elsewhere, highlighting the need to address control of these substances on the public health agenda.

Smoking behaviour and toxin exposure during six weeks use of a potential reduced exposure product: Omni

OBJECTIVE

To determine smoking behaviour, acceptability, and toxin exposure when smokers switch to the potential reduced exposure product-Omni cigarette.

DESIGN

12 week randomised, crossover study of Omni versus own cigarettes.

PARTICIPANTS

19 light/ultralight and 15 regular smokers.

OUTCOMES

Cigarettes/day, smoking topography, craving, withdrawal symptoms, urinary cotinine plus its glucuronide (total cotinine), nicotine plus its glucuronide (total nicotine), and carcinogen metabolites (4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol plus its glucuronides and 1-hydroxypyrene).

RESULTS

When switched to Omni, smokers smoked the same number of cigarettes/day, smoked Omni cigarettes less intensely (total puff volume = -11%) and had slightly lower total cotinine (-18%) levels than their own cigarettes, but had a slightly greater carbon monoxide boost/cig (+21%). Craving and withdrawal ratings were similar with Omni and own cigarettes. Carcinogen metabolite levels were somewhat but not significantly lower with Omni. About half of smokers rated Omni as better for their health and about two thirds stated it was weaker and worse tasting than their own cigarettes.

CONCLUSIONS

Although Omni may be an adequate behavioural and pharmacological substitute for traditional cigarettes, it may not decrease carcinogen exposure and may increase carbon monoxide. Replications with larger sample sizes and longer follow up are needed. These results indicate the need for regulation of reduced exposure and reduced risk claims.

Tobacco use in India: prevalence and predictors of smoking and chewing in a national cross sectional household survey

OBJECTIVE

To estimate the prevalence and the socioeconomic and demographic correlates of tobacco consumption in India.

DESIGN

Cross sectional, nationally representative population based household survey.

SUBJECTS

315 598 individuals 15 years or older from 91 196 households were sampled in National Family Health Survey-2 (1998-99). Data on tobacco consumption were elicited from household informants. Measures and methods: Prevalence of current smoking and current chewing of tobacco were used as outcome measures. Simple and two way cross tabulations and multivariate logistic regression analysis were the main analytical methods.

RESULTS

Thirty per cent of the population 15 years or older-47% men and 14% of women-either smoked or chewed tobacco, which translates to almost 195 million people-154 million men and 41 million women in India. However, the prevalence may be underestimated by almost 11% and 1.5% for chewing tobacco among men and women, respectively, and by 5% and 0.5% for smoking among men and women, respectively, because of use of household informants. Tobacco consumption was significantly higher in poor, less educated, scheduled castes and scheduled tribe populations. The prevalence of tobacco consumption increased up to the age of 50 years and then levelled or declined. The prevalence of smoking and chewing also varied widely between different states and had a strong association with individual's sociocultural characteristics.

CONCLUSION

The findings of the study highlight that an agenda to improve health outcomes among the poor in India must include effective interventions to control tobacco use. Failure to do so would most likely result in doubling the burden of diseases-both communicable and non-communicable-among India's teeming poor. There is a need for periodical surveys using more consistent definitions of tobacco use and eliciting information on different types of tobacco consumed. The study also suggests a need to adjust the prevalence estimates based on household informants.

ARTIST (Asian regional tobacco industry scientist team): Philip Morris' attempt to exert a scientific and regulatory agenda on Asia

OBJECTIVE

To describe how the transnational tobacco industry has collaborated with local Asian tobacco monopolies and companies to promote a scientific and regulatory agenda.

METHODS

Analysis of previously secret tobacco industry documents.

RESULTS

Transnational tobacco companies began aggressively entering the Asia market in the 1980s, and the current tobacco industry in Asia is a mix of transnational and local monopolies or private companies. Tobacco industry documents demonstrate that, in 1996, Philip Morris led an organisation of scientific representatives from different tobacco companies called the Asian Regional Tobacco Industry Science Team (ARTIST), whose membership grew to include monopolies from Korea, China, Thailand, and Taiwan and a company from Indonesia. ARTIST was initially a vehicle for PM's strategies against anticipated calls for global smoke-free areas from a World Health Organization secondhand smoke study. ARTIST evolved through 2001 into a forum to present scientific and regulatory issues faced primarily by Philip Morris and other transnational tobacco companies. Philip Morris' goal for the organisation became to reach the external scientific and public health community and regulators in Asia.

CONCLUSION

The Asian tobacco industry has changed from an environment of invasion by transnational tobacco companies to an environment of participation with Philip Morris' initiated activities. With this participation, tobacco control efforts in Asia face new challenges as Philip Morris promotes and integrates its scientific and regulatory agenda into the local Asian tobacco industry. As the local Asian tobacco monopolies and companies can have direct links with their governments, future implementation of effective tobacco control may be at odds with national priorities.

International rural health needs and services research: a nursing and midwifery response

As the importance of evidence-based practice in global health care increases, the need for constant, accurate feedback from those in practice is critical, yet the requirement to rapidly obtain and disseminate data on a global basis is a challenge for all health professionals. The Internet allows for global participation in data collection that dramatically streamlines the traditional survey process. This new paradigm applies to surveys that are short, issue focused, and time sensitive. The Global Network of World Health Organization (WHO) Collaborating Centres for Nursing and Midwifery Development used a sample of international nurses in 70 countries to identify the worldwide rural health issues of WHO priority health needs, treatment modalities, health care interventions, and providers, as well as the current state of rural health research on a global level. This article presents the results of the survey regarding rural health needs and nursing and midwifery's response to them internationally, demonstrates Internet data collection, and shows how this research paradigm can help establish an evidence base for nursing practice.

Opportunities for cancer epidemiology in developing countries

Most cancer epidemiology studies involve people living in North America and Europe, which represent only a fraction of the global population. The wide variety of dietary, lifestyle and environmental exposures, as well as the genetic variation among people in developing countries can provide valuable new information on factors that contribute to cancer or that protect against it. What are the challenges and advantages to performing large epidemiological studies in developing nations?

Patterns and distribution of tobacco consumption in India: cross sectional multilevel evidence from the 1998-9 national family health survey

OBJECTIVE

To investigate the demographic, socioeconomic, and geographical distribution of tobacco consumption in India.

DESIGN

Multilevel cross sectional analysis of the 1998-9 Indian national family health survey of 301 984 individuals in 92 447 households in 3215 villages in 440 districts in 26 states.

SETTING

Indian states.

PARTICIPANTS

301 984 adults (> or = 18 years).

MAIN OUTCOME MEASURES

Dichotomous variable for smoking and chewing tobacco for each respondent (1 if yes, 0 if no) as well as a combined measure of whether an individual smokes, chews tobacco, or both.

RESULTS

Smoking and chewing tobacco are systematically associated with socioeconomic markers at the individual and household level. Individuals with no education are 2.69 times more likely to smoke and chew tobacco than those with postgraduate education. Households belonging to the lowest fifth of a standard of living index were 2.54 times more likely to consume tobacco than those in the highest fifth. Scheduled tribes (odds ratio 1.23, 95% confidence interval 1.18 to 1.29) and scheduled castes (1.19, 1.16 to 1.23) were more likely to consume tobacco than other caste groups. The socioeconomic differences are more marked for smoking than for chewing tobacco. Socioeconomic markers and demographic characteristics of individuals and households do not account fully for the differences at the level of state, district, and village in smoking and chewing tobacco, with state accounting for the bulk of the variation in tobacco consumption.

CONCLUSION

The distribution of tobacco consumption is likely to maintain, and perhaps increase, the current considerable socioeconomic differentials in health in India. Interventions aimed at influencing change in tobacco consumption should consider the socioeconomic and geographical determinants of people's susceptibility to consume tobacco.

Estimates of global mortality attributable to smoking in 2000

BACKGROUND

Smoking is a risk factor for several diseases and has been increasing in many developing countries. Our aim was to estimate global and regional mortality in 2000 caused by smoking, including an analysis of uncertainty.

METHODS

Following the methods of Peto and colleagues, we used lung-cancer mortality as an indirect marker for accumulated smoking risk. Never-smoker lung-cancer mortality was estimated based on the household use of coal with poor ventilation. Relative risks were taken from the American Cancer Society Cancer Prevention Study, phase II, and the retrospective proportional mortality analysis of Liu and colleagues in China. Relative risks were corrected for confounding and extrapolation to other regions.

RESULTS

We estimated that in 2000, 4.83 (uncertainty range 3.94-5.93) million premature deaths in the world were attributable to smoking; 2.41 (1.80-3.15) million in developing countries and 2.43 (2.13-2.78) million in industrialised countries. 3.84 million of these deaths were in men. The leading causes of death from smoking were cardiovascular diseases (1.69 million deaths), chronic obstructive pulmonary disease (0.97 million deaths), and lung cancer (0.85 million deaths).

INTERPRETATION

Smoking was an important cause of global mortality in 2000. In view of the expected demographic and epidemiological transitions and current smoking patterns in the developing world, the health loss due to smoking will grow even larger unless effective interventions and policies that reduce smoking among men and prevent increases among women in developing countries are implemented.

Slowing the epidemic of tobacco use among Asian Americans and Pacific Islanders

Data on tobacco use among the Asian American/Pacific Islander (AAPI) population remain limited, although existing studies indicate that tobacco use prevalence among males from specific AAPI groups is significantly higher than in the general US male population. This high prevalence of tobacco use and the disparities in use result from social norms, targeted marketing by the tobacco industry, lack of culturally and linguistically tailored prevention and control programs, and limited impact of mainstream tobacco control programs for AAPIs. We review the available literature on tobacco use among AAPI men and women, highlight a national agenda that promotes tobacco prevention and control for AAPI communities, and acknowledge recent trends including the increase of tobacco use among AAPI women and girls.

Measuring the accumulated hazards of smoking: global and regional estimates for 2000

OBJECTIVE

Current prevalence of smoking, even where data are available, is a poor proxy for cumulative hazards of smoking, which depend on several factors including the age at which smoking began, duration of smoking, number of cigarettes smoked per day, degree of inhalation, and cigarette characteristics such as tar and nicotine content or filter type.

METHODS

We extended the Peto-Lopez smoking impact ratio method to estimate accumulated hazards of smoking for different regions of the world. Lung cancer mortality data were obtained from the Global Burden of Disease mortality database. The American Cancer Society Cancer Prevention Study, phase II (CPS-II) with follow up for the years 1982 to 1988 was the reference population. For the global application of the method, never-smoker lung cancer mortality rates were chosen based on the estimated use of coal for household energy in each region.

RESULTS

Men in industrialised countries of Europe, North America, and the Western Pacific had the largest accumulated hazards of smoking. Young and middle age males in many regions of the developing world also had large smoking risks. The accumulated hazards of smoking for women were highest in North America followed by Europe.

CONCLUSIONS

In the absence of detailed data on smoking prevalence and history, lung cancer mortality provides a robust indicator of the accumulated hazards of smoking. These hazards in developing countries are currently more concentrated among young and middle aged males.