Impact on cardiovascular disease events of the implementation of Argentina's national tobacco control law

The potential impact of policies and structural interventions in reducing cardiovascular disease and mortality: a systematic review of simulation-based studies

Background

The aim of the study was to investigate the potential effect of different structural interventions for preventing cardiovascular disease.

Methods

Medline and EMBASE were searched for peer-reviewed simulation-based studies of structural interventions for prevention of cardiovascular disease. We performed a systematic narrative synthesis.

Results

A total of 54 studies met the inclusion criteria. Diet, nutrition, tobacco and alcohol control and other programmes are among the policy simulation models explored. Food tax and subsidies, healthy food and lifestyles policies, palm oil tax, processed meat tax, reduction in ultra-processed foods, supplementary nutrition assistance programmes, stricter food policy and subsidised community-supported agriculture were among the diet and nutrition initiatives. Initiatives to reduce tobacco and alcohol use included a smoking ban, a national tobacco control initiative and a tax on alcohol. Others included the NHS Health Check, WHO 25 × 25 and air quality management policy.

Future work and limitations

There is significant heterogeneity in simulation models, making comparisons of output data impossible. While policy interventions typically include a variety of strategies, none of the models considered possible interrelationships between multiple policies or potential interactions. Research that investigates dose-response interactions between numerous modifications as well as longer-term clinical outcomes can help us better understand the potential impact of policy-level interventions.

Conclusions

The reviewed studies underscore the potential of structural interventions in addressing cardiovascular diseases. Notably, interventions in areas such as diet, tobacco, and alcohol control demonstrate a prospective decrease in cardiovascular incidents. However, to realize the full potential of such interventions, there is a pressing need for models that consider the interplay and cumulative impacts of multiple policies. Rigorous research into holistic and interconnected interventions will pave the way for more effective policy strategies in the future.

Study registration

The study is registered as PROSPERO CRD42019154836.

Funding

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 17/148/05.

Prevalence and correlates of current cigarette smoking among transgender women in Argentina

Objective

To assess the prevalence of current cigarette smoking among transgender women in Argentina, and to examine the unique associations of current cigarette smoking with demographic and psychosocial factors.

Methods

This study is a secondary data analysis of the TransCITAR - a prospective cohort study of transgender individuals living in Buenos Aires, Argentina - baseline data. The baseline survey collected information on sociodemographic characteristics, perceived health status, depressive symptoms, suicide attempts, current cigarette smoking, alcohol use disorder, and substance use. Participants were also asked about lifetime experiences of physical and sexual violence perpetrated by partners, clients and/or the police, and experiences of gender identity stigma in the past year from healthcare workers and the police. Lastly, participants were asked if they had ever been arrested. Fisher's exact test was used to compare proportions in categorical variables and student t-test was used for continuous variables. Significant associations with current cigarette smoking were tested in a logistic regression model adjusted for all significant associations.

Results

A total of 41.7% of participants (n = 393) reported current cigarette smoking. Compared to their non-smoking counterparts, participants who reported current cigarette smoking (1) had completed less education, (2) were more likely to be born in Argentina, (3) more likely to had migrated to Buenos Aires from other parts of the country, (4) more likely to report a history of sex work, (5) more likely to perceive their health as excellent, (6) more likely to screen positive for hazardous alcohol drinking, (7) more likely to report any substance and cocaine use in the past year, (8) more likely to experience gender identity stigma from the police in the past year, and (9) more likely to being arrested in their lifetime (all p's < 0.05). After controlling for all significant associations, education level of less than high school (AOR = 1.79, 95% CI 1.02-2.12), hazardous drinking (AOR = 2.65, 95% CI 1.30-5.37), and any substance use in the last year (AOR = 2.14, 95% CI 1.16-3.94) were positively and independently associated with current cigarette smoking.

Conclusion

Among transgender women in Argentina, current cigarette smoking was more than double the rate for cisgender women. Current cigarette smoking was associated with education, hazardous drinking, and any drug use. These results will inform future smoking cessation interventions among transgender women in Argentina.

Identifying best modelling practices for tobacco control policy simulations: a systematic review and a novel quality assessment framework

BACKGROUND

Policy simulation models (PSMs) have been used extensively to shape health policies before real-world implementation and evaluate post-implementation impact. This systematic review aimed to examine best practices, identify common pitfalls in tobacco control PSMs and propose a modelling quality assessment framework.

METHODS

We searched five databases to identify eligible publications from July 2013 to August 2019. We additionally included papers from Feirman et al for studies before July 2013. Tobacco control PSMs that project tobacco use and tobacco-related outcomes from smoking policies were included. We extracted model inputs, structure and outputs data for models used in two or more included papers. Using our proposed quality assessment framework, we scored these models on population representativeness, policy effectiveness evidence, simulated smoking histories, included smoking-related diseases, exposure-outcome lag time, transparency, sensitivity analysis, validation and equity.

FINDINGS

We found 146 eligible papers and 25 distinct models. Most models used population data from public or administrative registries, and all performed sensitivity analysis. However, smoking behaviour was commonly modelled into crude categories of smoking status. Eight models only presented overall changes in mortality rather than explicitly considering smoking-related diseases. Only four models reported impacts on health inequalities, and none offered the source code. Overall, the higher scored models achieved higher citation rates.

CONCLUSIONS

While fragments of good practices were widespread across the reviewed PSMs, only a few included a 'critical mass' of the good practices specified in our quality assessment framework. This framework might, therefore, potentially serve as a benchmark and support sharing of good modelling practices.

Impacto sanitario de la prohibición total de publicidades de tabaco en argentina

Health impact of the total ban on advertising of tobacco productsThe objective was to estimate the health impact of the total ban on advertising of tobacco products in terms of avoided cardiovascular events in those over 35 years of age in Argentina.The Cardiovascular Disease Policy Model (CVDPM) was used, which is a Markov simulation model used to represent and project mortality and morbidity due to cardiovascular disease (CVD) in the population aged 35 or over. It constitutes a demographic-epidemiological model, which represents the population between 35 and 95 years of age and uses a logistic regression model based on the Framingham equation to estimate the annual incidence of cardiovascular disease. We assumed that implementing a complete ban on the advertising of tobacco products would lead to a 9% reduction in tobacco consumption.The complete ban on advertising could prevent 15,164 deaths over a period of 10 years, of which 2610 would be the result of coronary heart disease and 747 due to stroke. These reductions would mean an annual decrease of 0.46% of total deaths, 0.60% of deaths from coronary heart disease and 0.33% in deaths from stroke. In addition, during the same period, it would avoid 6630 acute myocardial infarctions and 2851 strokes (reductions of 1.35% and 0.40%, respectively).We hope that these findings might contribute to the strengthening of sanitary tobacco control policies in Argentina based on the remarkable benefits of banning the advertising of tobacco products in full and in line with current global recommendations.

Impacts of local public smoking bans on smoking behaviors and tobacco smoke exposure

This paper examines the immediate and long-term effects of public smoking bans on smoking prevalence, smoking regularity, smoking intensity, and secondhand tobacco smoke exposure. We supplement the extensive literature on the effects of various types of tobacco control legislation on smoking behavior in developed countries by studying the provincial smoking bans and more recent national ban of a middle-income country, Argentina. We focus on the difference between full and partial smoking bans, and take advantage of the time and province variation in ban implementation in order to determine the causal effects of each type of ban. We find that full bans reduce national smoking prevalence over time, especially among younger demographic groups, but have no significant impact on intensity of smoking among smokers. Full bans also benefit nonsmokers, as they are associated with a significant reduction in environmental tobacco smoke exposure. Partial bans do not significantly impact smoking prevalence, and are found to increase smoking intensity among individuals who smoke every day. These findings provide support for ratification of full bans by all provinces according to the National Tobacco Control Law of 2011.

Impact of a comprehensive tobacco control policy package on acute myocardial infarction and stroke hospital admissions in Beijing, China: interrupted time series study

OBJECTIVE

To evaluate a comprehensive tobacco control policy package on hospital admissions for acute myocardial infarction (AMI) and stroke in a global city.

DESIGN

Interrupted time series study.

SETTING

Beijing, China.

POPULATION

31 707 AMI and 128 116 stroke hospital admissions recorded by the Beijing Medical Claim Data for Employees in 17.7 million residents from January 2013 to June 2017.

INTERVENTION

The policy package including all components of MPOWER has been implemented since June 2015.

MAIN OUTCOME MEASURES

The immediate change of AMI and stroke hospital admissions and the annual change in the secular trend.

RESULTS

There was a secular increase trend for the crude hospital admission rates of AMI and stroke during the observational period. After implementation of the policy, immediate reductions were observed in the hospital admissions for both AMI (-5.4%, 95% CI -10.0% to -0.5%) and stroke (-5.6%, 95% CI -7.8% to -3.3%). In addition, the secular increase trend for stroke was slowed down by -15.3% (95% CI -16.7% to -13.9%) annually. Compared with the hypothetical scenario where the policy had not taken place, an estimated 18 137 (26.7%) stroke hospital admissions had been averted during the 25 months of postpolicy period.

CONCLUSIONS

The results indicated significant health benefits on cardiovascular morbidity after the Beijing tobacco control policy package, which highlighted the importance for a comprehensive tobacco control policy at the national level in China. Similar tobacco control policy which consists of all components of MPOWER is urgently needed in other areas, especially in settings with high tobacco consumption, to achieve greater public health gains.

Projected impact of a reduction in sugar-sweetened beverage consumption on diabetes and cardiovascular disease in Argentina: A modeling study

BACKGROUND

Sugar-sweetened beverage (SSB) consumption is associated with obesity, diabetes, and hypertension. Argentina is one of the major consumers of SSBs per capita worldwide. Determining the impact of SSB reduction on health will inform policy debates.

METHODS AND FINDINGS

We used the Cardiovascular Disease Policy Model-Argentina (CVD Policy Model-Argentina), a local adaptation of a well-established computer simulation model that projects cardiovascular and mortality events for the population 35-94 years old, to estimate the impact of reducing SSB consumption on diabetes incidence, cardiovascular events, and mortality in Argentina during the period 2015-2024, using local demographic and consumption data. Given uncertainty regarding the exact amount of SSBs consumed by different age groups, we modeled 2 estimates of baseline consumption (low and high) under 2 different scenarios: a 10% and a 20% decrease in SSB consumption. We also included a range of caloric compensation in the model (0%, 39%, and 100%). We used Monte Carlo simulations to generate 95% uncertainty intervals (UIs) around our primary outcome measures for each intervention scenario. Over the 2015-2024 period, a 10% reduction in SSBs with a caloric compensation of 39% is projected to reduce incident diabetes cases by 13,300 (95% UI 10,800-15,600 [low SSB consumption estimate]) to 27,700 cases (95% UI 22,400-32,400 [high SSB consumption estimate]), i.e., 1.7% and 3.6% fewer cases, respectively, compared to a scenario of no change in SSB consumption. It would also reduce myocardial infarctions by 2,500 (95% UI 2,200-2,800) to 5,100 (95% UI 4,500-5,700) events and all-cause deaths by 2,700 (95% UI 2,200-3,200) to 5,600 (95% UI 4,600-6,600) for "low" and "high" estimates of SSB intake, respectively. A 20% reduction in SSB consumption with 39% caloric compensation is projected to result in 26,200 (95% UI 21,200-30,600) to 53,800 (95% UI 43,900-62,700) fewer cases of diabetes, 4,800 (95% UI 4,200-5,300) to 10,000 (95% UI 8,800-11,200) fewer myocardial infarctions, and 5,200 (95% UI 4,300-6,200) to 11,000 (95% UI 9,100-13,100) fewer deaths. The largest reductions in diabetes and cardiovascular events were observed in the youngest age group modeled (35-44 years) for both men and women; additionally, more events could be avoided in men compared to women in all age groups. The main limitations of our study are the limited availability of SSB consumption data in Argentina and the fact that we were only able to model the possible benefits of the interventions for the population older than 34 years.

CONCLUSIONS

Our study finds that, even under conservative assumptions, a relatively small reduction in SSB consumption could lead to a substantial decrease in diabetes incidence, cardiovascular events, and mortality in Argentina.

An evaluation of the impact of aggressive hypertension, diabetes and smoking cessation management on CVD outcomes at the population level: a dynamic simulation analysis

Background

Evidence from randomized control trials suggest that coupled with smoking cessation interventions, CVD events can be reduced significantly if hypertension and diabetes patients are properly managed, raising practical what-if questions at the population level. This research aims to develop a dynamic simulation model using the systems modelling methodology of system dynamics, to evaluate the medium to long-term impact of hypertension and diabetes management, as well as smoking cessation intervention on CVD events, CVD deaths and post-CVD population.

Methods

The systems modelling methodology of system dynamics was used to develop a simulation model to evaluate the impact of aggressive hypertension, diabetes and smoking cessation management on CVD outcomes at the population level.

Result

The insights from this research suggest that despite that at the individual level, hypertension management is associated with the highest risk reduction for CVD (50%) compared to diabetes and smoking (20%) and is also the most prevalent risk factor, at the population level, diabetes management interventions are projected to have higher impact on reducing CVD events compared to hypertension management or smoking cessation interventions. However, a combined intervention of diabetes and hypertension management, as well as smoking cessation has the most impact on CVD outcomes.

Conclusion

Due to aging population and the increasing prevalence of chronic conditions in Singapore, the number of CVD events in Singapore is projected to rise significantly in the near future—hence the need for proactive planning to implement needed interventions. Findings from this research suggest that CVD events and its associated deaths and disabilities could be reduced significantly if diabetes and hypertension patients are aggressively managed.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7429-2) contains supplementary material, which is available to authorized users.

[Behavioral changes in smokers after implementation of anti-smoking legislation in ArgentinaMudança de comportamento nos fumantes após a implementação da legislação antifumo na Argentina]

OBJECTIVE

Identify factors related to behavioral changes in smokers over 18 years of age following implementation of provincial policies for 100% smoke-free spaces in Argentina.

METHODS

A cross-sectional analytical study was conducted. The multilevel technique was used with data from different hierarchies. Secondary data sources were used: National Risk Factor Surveys 2005, 2009, and 2013.

RESULTS

The individual analysis of explanatory variables revealed that residents of provinces that do not have smoke-free legislation were 40% less likely to consider quitting smoking than people who live in provinces with such legislation. In provinces without smoke-free spaces, males over 65 years old are even less likely to think about quitting smoking.

CONCLUSIONS

The results suggest that legislation based on Article 8 of the Framework Convention would be effective in promoting tobacco cessation in Argentina.

Community-based cardiovascular health promotion in Argentina. A systematic review

In Argentina, cardiovascular disease (CVD) accounts for 30% of deaths and more than 600 000 disability-adjusted life years. However, no reviews describing local studies on interventions to address CVD risk factors have been identified. The purpose of this study is to characterize those population-based interventions and public policies implemented in Argentina to reduce the burden of cardiovascular disease with an adequate evaluation of their impact on population health. We conducted a systematic review of studies that assessed interventions in health promotion and/or primary prevention conducted in adult populations of Argentina, addressing specific CVD factors, from 1999 to 2016. We searched major bibliographic databases, grey literature, ministries and secretariats of health, and academic national libraries. Key informants, non-governmental organizations, universities, hospitals and experts were also contacted. We applied specific inclusion criteria. We assessed the methodological quality of the studies and reported the effectiveness and impact of population interventions and policies, as well as process evaluations' characteristics. After removing duplicates we identified 1686 references from databases. After reviewing title and abstracts 18 studies were selected, five of them corresponded to evaluations of public policies-all addressing tobacco smoking. We presented a structured review of each experience. Most of the studies were deemed to entail moderate or high risk of bias. We summarized the findings and characteristics of these studies, including implementation strategies, process and impact evaluation. This is the first systematic review of interventions focused on primary prevention and health promotion to counter CVD and diabetes in Argentina.

The distribution of cardiac diagnostic testing for acute coronary syndrome in the Brazilian healthcare system: A national geospatial evaluation of health access

BACKGROUND

Little is known about the utilization of cardiac diagnostic testing in Brazil and how such testing is related with local rates of acute coronary syndrome (ACS)-related mortality.

METHODS AND RESULTS

Using data from DATASUS, the public national healthcare database, absolute counts of diagnostic tests performed were calculated for each of the 5570 municipalities and mapped. Spatial error regression and geographic weighted regression models were used to describe the geographic variation in the association between ACS mortality, income, and access to diagnostic testing. From 2008 to 2014, a total of 4,653,884 cardiac diagnostic procedures were performed in Brazil, at a total cost of $271 million USD. The overall ACS mortality rate during this time period was 133.8 deaths per 100,000 inhabitants aged 20 to 79. The most commonly utilized test was the stress ECG (3,015,993), followed by catheterization (862,627), scintigraphy (669,969) and stress echocardiography (105,295). The majority of these procedures were conducted in large urban centers in more economically developed regions of the country. Increased access to testing and increased income were not uniformly associated with decreased ACS mortality, and tremendous geographic heterogeneity was observed in the relationship between these variables.

CONCLUSIONS

The majority of testing for ACS in Brazil is conducted at referral centers in developed urban settings. Stress ECG is the dominant testing modality in use. Increased access to diagnostic testing was not consistently associated with decreased ACS mortality across the country.

Distributional benefits of tobacco tax and smoke-free workplaces in China: A modeling study

Background

Tobacco taxation and smoke–free workplaces reduce smoking, tobacco–related premature deaths and associated out–of–pocket health care expenditures. We examine the distributional consequences of a price increase in tobacco products through an excise tax hike, and of an implementation of smoke–free workplaces, in China.

Methods

We use extended cost–effectiveness analysis (ECEA) to evaluate, across income quintiles of the male population (the large majority of Chinese smokers), the premature deaths averted, the change in tax revenues generated, and the financial risk protection procured (eg, poverty cases averted, defined as the number of individuals no longer facing tobacco–related out–of–pocket expenditures for disease treatment, that would otherwise impoverish them), that would follow a 75% increase in cigarette prices through substantial increments in excise tax fully passed onto consumers, and a nationwide total implementation of workplace smoking bans.

Results

A 75% increase in cigarette prices would avert about 24 million premature deaths among the current Chinese male population, with a third among the bottom income quintile, increase additional tax revenues by US$ 46 billion annually, and prevent around 9 million poverty cases, 19% of which among the bottom income quintile. Implementation of smoking bans in workplaces would avert about 12 million premature deaths, with a fifth among the bottom income quintile, decrease tax revenues by US$ 7 billion annually, and prevent around 4 million poverty cases, 12% of which among the bottom income quintile.

Conclusions

Increased excise taxes on tobacco products and workplace smoking bans can procure large health and economic benefits to the Chinese population, especially among the poor.

Strategies to Improve Stroke Care Services in Low- and Middle-Income Countries: A Systematic Review

Background: The burden of stroke in low- and middle-income countries (LMICs) is large and increasing, challenging the already stretched health-care services. Aims and Objectives: To determine the quality of existing stroke-care services in LMICs and to highlight indigenous, inexpensive, evidence-based implementable strategies being used in stroke-care. Methods: A detailed literature search was undertaken using PubMed and Google scholar from January 1966 to October 2015 using a range of search terms. Of 921 publications, 373 papers were shortlisted and 31 articles on existing stroke-services were included. Results: We identified efficient models of ambulance transport and pre-notification. Stroke Units (SU) are available in some countries, but are relatively sparse and mostly provided by the private sector. Very few patients were thrombolysed; this could be increased with telemedicine and governmental subsidies. Adherence to secondary preventive drugs is affected by limited availability and affordability, emphasizing the importance of primary prevention. Training of paramedics, care-givers and nurses in post-stroke care is feasible. Conclusion: In this systematic review, we found several reports on evidence-based implementable stroke services in LMICs. Some strategies are economic, feasible and reproducible but remain untested. Data on their outcomes and sustainability is limited. Further research on implementation of locally and regionally adapted stroke-services and cost-effective secondary prevention programs should be a priority.

Comparing Strategies for Lipid Lowering in Argentina: An Analysis from the CVD Policy Model-Argentina

INTRODUCTION

In Argentina, the national guidelines for lipid control emphasize the use of relatively inexpensive low- or moderate-potency statins by patients at high risk (>20 %) of a cardiovascular event. The objective of this study was to compare the impact and costs of the current national CVD prevention guidelines with regard to morbidity and mortality in Argentina with the impact and costs of three strategies that incorporate high-potency statins.

METHODS

We used the CVD Policy Model-Argentina to model the proposed interventions. This model is a national-scale, state-transition (Markov) computer simulation model of the CVD incidence, prevalence, mortality, and costs in adults 35-84 years of age. We modeled three scenarios: scenario 1 lowers the risk threshold for treatment to >10 % according the Framingham Risk Score (FRS); scenario 2 intensifies statin potency under current treatment thresholds; and scenario 3 combines both scenarios by lowering the treatment threshold to ≥10 % FRS and intensifying statin potency.

RESULTS

Scenario 1 would translate into 1400 fewer MIs and 500 fewer CHD deaths every year, a 3 % and 2 % reduction, respectively. Scenario 2 would lead to 2000 fewer MIs and 1000 fewer CHD deaths every year. Scenario 3 would result in the greatest reduction in MIs and CHD deaths, with 3400 fewer MIs and 1400 fewer CHD deaths every year, which translates to a 7 % and 6 % reduction, respectively. All scenarios were cost-effective if the cost of a high-potency statin pill was under US$0.25.

CONCLUSION

Incorporating those individuals with greater than 10 % cardiovascular risk and the use of high-potency statins into Argentina's national lipid guidelines could result in fewer CHD deaths and events at a reasonable cost.

Validation of Non-Smoking Status by Spouse Following a Cessation Intervention

BACKGROUND

Following cessation interventions, self-reported smoking abstinence with biochemical verification is the "gold standard" for defining outcomes. Because obtaining biochemical verification is challenging in community studies, we compared self-reported cessation among smokers completing treatment to the smoking status reported by each participant's spouse or proxy.

METHOD

Participants were smokers who had reported quitting 12 months after a cessation intervention. Participants had either attended a smoking cessation clinic or they were patients seen by physicians who had recently participated in a cessation-training program. Proxies living with these participants were interviewed by telephone to ask about their partner's smoking status. We compared the participants' responses to those from their spouses.

RESULTS

At 12 months, 346 of 1423 baseline smokers had quit; 161/346 reported non-smokers were called and 140 proxies were interviewed. The participants averaged 51 years of age, 69% were women. At baseline, the mean number of cigarettes smoked per day was 20.1 (SD = 9.9) and the average number of quit attempts was 2.4 (SD = 1.2). Cessation methods used were medical advice (21%) and/or pharmacotherapy (79%). Of the 140 spouses interviewed, only 10 (7.1%) reported that their partners were currently smoking.

CONCLUSIONS

Proxy-reported data on smoking status could be used to validate self-report.

Mathematical Modeling in Tobacco Control Research: Initial Results From a Systematic Review

OBJECTIVES

The US Food and Drug Administration has expressed interest in using mathematical models to evaluate potential tobacco policies. The goal of this systematic review was to synthesize data from tobacco control studies that employ mathematical models.

METHODS

We searched five electronic databases on July 1, 2013 to identify published studies that used a mathematical model to project a tobacco-related outcome and developed a data extraction form based on the ISPOR-SMDM Modeling Good Research Practices. We developed an organizational framework to categorize these studies and identify models employed across multiple papers. We synthesized results qualitatively, providing a descriptive synthesis of included studies.

RESULTS

The 263 studies in this review were heterogeneous with regard to their methodologies and aims. We used the organizational framework to categorize each study according to its objective and map the objective to a model outcome. We identified two types of study objectives (trend and policy/intervention) and three types of model outcomes (change in tobacco use behavior, change in tobacco-related morbidity or mortality, and economic impact). Eighteen models were used across 118 studies.

CONCLUSIONS

This paper extends conventional systematic review methods to characterize a body of literature on mathematical modeling in tobacco control. The findings of this synthesis can inform the development of new models and the improvement of existing models, strengthening the ability of researchers to accurately project future tobacco-related trends and evaluate potential tobacco control policies and interventions. These findings can also help decision-makers to identify and become oriented with models relevant to their work.

Cross-Cultural Adaptation of a Text Message-Based Program for Smoking Cessation in Buenos Aires, Argentina

INTRODUCTION

Few individual-level nonpharmacological interventions are available in Argentina to support smokers who attempt to quit.

METHODS

We conducted a cross-cultural adaptation of Stop Smoking with Mobile Phones, an English text message-based tobacco cessation program, in Buenos Aires. The process included English-Spanish translation and back-translation, face validity checking by two local tobacco cessation experts, and a complete review using a structured questionnaire and discussion groups with potential users (current smokers who want to quit or former smokers who quit in the past 6 months). An editing group was responsible for analyzing information collected and preparing adapted messages. Readability of final messages was assessed.

RESULTS

Tobacco cessation experts found translated messages suitable for the local setting, although mention of "mate" (a local infusion which can trigger cravings) was recommended. Review of messages by two potential users confirmed most of the messages would help smokers to quit and resulted in minor edits. Potential users who participated in two discussion groups (n = 17, 64.7% female, age range: 30-73) found the content of messages was relevant for cessation and related to their own experiences, although they suggested adding information regarding the negative consequences of smoking. Participants emphasized that messages should be formatted using voseo and informal style and provided feedback on specific words and expressions. Readability of final messages was easy/very easy (Fernández Huerta Index: 79.93).

CONCLUSION

The cross-cultural adaptation of Stop Smoking with Mobile Phones resulted in relevant revisions for the study population, including tone, wording, and pertinent information (eg, smoking consequences). Local acceptability and effectiveness should be confirmed in future studies.

The sociodemographic patterning of opposition to raising taxes on tobacco and restricting tobacco advertisements in Argentina

BACKGROUND

Argentina has enacted important tobacco control initiatives in recent years. Yet little is known about the social patterning of attitudes toward tobacco control. Research is needed to explore what predicts opposition to tobacco control initiatives such as higher taxes on tobacco and the prohibition of tobacco advertising.

STUDY DESIGN

Secondary analysis of Argentina's Global Adult Tobacco Survey (N = 6645).

METHODS

Binary logistic regression analysis examining opposition to raising tobacco taxes and banning tobacco publicity. Models were stratified by smoking status.

RESULTS

Respondents generally indicated very little opposition to either tobacco control measure, with only 15.6% of respondents opposed to increasing taxes on tobacco products and 9.6% opposed to banning tobacco advertisements. Smoking status is the most important predictor of opposition to increasing taxes (OR = 7.85, 95% CI = 6.60-9.34) and banning advertisements (OR = 1.72, 95% CI = 1.39-2.11). Opposition to these measures is most likely among young respondents (aged 15-24) and least likely among older age groups (55-64 and 65 or over), compared to the 25-34 age group. Stratified models suggest that the effect of age may be different for smokers and non-smokers. Low income is a significant predictor of opposition, but only in stratified models for smokers.

CONCLUSION

There is general support for stronger tobacco control measures in Argentina. Opposition to raising taxes on tobacco products and banning tobacco advertisement appears to be concentrated among young smokers with low and medium levels of household income.

Smoking behavior and use of tobacco industry sponsored websites among medical students and young physicians in Argentina

Background

Internet-based marketing has become an attractive option for promoting tobacco products due to its potential to avoid advertising restrictions. In Argentina, several cigarette brands have designed websites for the local market, which promote user participation.

Objective

The intent of the study was to report on the use of tobacco company-sponsored websites by medical students and recently graduated physicians.

Methods

An online self-administered survey was conducted among eligible medical students and recent graduates from the University of Buenos Aires (UBA). Sampling was from lists of email addresses of students enrolled in two required courses. Eligibility criteria were ages 18-30 years and reporting on smoking status. Questions on Internet use included accessing a tobacco brand website at least once during their lifetime and any use of tobacco promotional materials.

Results

The response rate was 35.08% (1743/4969). The final sample included 1659 participants: 73.06% (1212/1659) were women and mean age was 26.6 years (SD 1.9). The majority were current medical students (55.70%, 924/1659) and 27.31% (453/1659) were current smokers. Men were more likely to report having seen a tobacco advertisement on the Internet (P=.001), to have received a tobacco promotion personally addressed to them (P=.03), to have used that promotion (P=.02), and to have accessed a tobacco-sponsored website (P=.01). Among respondents, 19.35% (321/1659) reported having accessed a tobacco-sponsored website at least once in their lifetime and almost all of them (93.8%, 301/321) accessed these sites only when it was necessary for participating in a marketing promotion. Most people logging on for promotions reported entering once a month or less (58.9%, 189/321), while 25.5% (82/321) reported accessing the tobacco industry Internet sites once a week or more. In adjusted logistic regression models, participants were more likely to have accessed a tobacco brand website if they were former smokers (OR 2.45, 95% CI 1.42-4.22) or current (OR 8.12, 95% CI 4.66-14.16), if they reported having seen a tobacco advertisement on the Internet (OR 2.44, 95% CI 1.77-3.37), received a tobacco promotion personally addressed to them (OR 5.62; 95% CI 4.19-7.55), or used one of these promotions (OR 14.05, 95% CI 9.21-21.43). Respondents were more likely to be current smokers if they received a tobacco promotion (OR 2.64, 95% CI 2.02-3.45) or if they used one of these promotions (OR 1.93, 95% CI 1.31-2.85).

Conclusions

Our study suggests that tobacco industry websites reach medical students and young physicians in a middle-income country with their marketing promotions. Current or proposed legislation to ban tobacco advertising needs to include Internet sites and related social media.

Projected impact of a sodium consumption reduction initiative in Argentina: an analysis from the CVD policy model--Argentina

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in adults in Argentina. Sodium reduction policies targeting processed foods were implemented in 2011 in Argentina, but the impact has not been evaluated. The aims of this study are to use Argentina-specific data on sodium excretion and project the impact of Argentina's sodium reduction policies under two scenarios - the 2-year intervention currently being undertaken or a more persistent 10 year sodium reduction strategy.

METHODS

We used Argentina-specific data on sodium excretion by sex and projected the impact of the current strategy on sodium consumption and blood pressure decrease. We assessed the projected impact of sodium reduction policies on CVD using the Cardiovascular Disease (CVD) Policy Model, adapted to Argentina, modeling two alternative policy scenarios over the next decade.

RESULTS

Our study finds that the initiative to reduce sodium consumption currently in place in Argentina will have substantial impact on CVD over the next 10 years. Under the current proposed policy of 2-year sodium reduction, the mean sodium consumption is projected to decrease by 319-387 mg/day. This decrease is expected to translate into an absolute reduction of systolic blood pressure from 0.93 mmHg to 1.81 mmHg. This would avert about 19,000 all-cause mortality, 13,000 total myocardial infarctions, and 10,000 total strokes over the next decade. A more persistent sodium reduction strategy would yield even greater CVD benefits.

CONCLUSION

The impact of the Argentinean initiative would be effective in substantially reducing mortality and morbidity from CVD. This paper provides evidence-based support to continue implementing strategies to reduce sodium consumption at a population level.

Links between socio-economic circumstances and changes in smoking behavior in the Mexican population: 2002-2010

While deleterious consequences of smoking on health have been widely publicized, in many developing countries, smoking prevalence is high and increasing. Little is known about the dynamics underlying changes in smoking behavior. This paper examines socio-economic and demographic characteristics associated with smoking initiation and quitting in Mexico between 2002 and 2010. In addition to the influences of age, gender, education, household economic resources and location of residence, changes in marital status, living arrangements and health status are examined. Drawing data from the Mexican Family Life Survey, a rich population-based longitudinal study of individuals, smoking behavior of individuals in 2002 is compared with their behavior in 2010. Logistic models are used to examine socio-demographic and health factors that are associated with initiating and quitting smoking. There are three main findings. First, part of the relationship between education and smoking reflects the role of economic resources. Second, associations of smoking with education and economic resources differ for females and males. Third, there is considerable heterogeneity in the factors linked to smoking behavior in Mexico indicating that the smoking epidemic may be at different stages in different population subgroups. Mexico has recently implemented fiscal policies and public health campaigns aimed at reducing smoking prevalence and discouraging smoking initiation. These programs are likely to be more effective if they target particular socio-economic and demographic sub-groups.