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World Health Organization

GLOBAL TOBACCO SURVEILLANCE SYSTEM

Chairperson: Dr Sonali Jhanjee


Presenter:

Dr Saurabh Kumar

SCOPE OF THE SEMINAR


INTRODUCTION OVERVIEW COMPONENTS
GYTS GSPS GHPSS GATS

LINKING THE DATA TO CONTROL POLICIES LIMITATIONS FUTURE DIRECTION

INTRODUCTION
Tobacco is the single greatest preventable cause of death in the world today >1 billion people worldwide currently smoke tobacco More than 600 million people alive today will die from smoking-related causes; half of them children. Cigarettes kill half of all lifetime users. Half of all deaths from smoking occur in middle age between 35 and 69 years old, when individuals are most productive.

TOBACCO USE IS THE MAJOR RISK FACTOR FOR ALL 4 LEADING NCD
The UN High-Level Meeting on NonCommunicable Diseases (NCDs) in September, 2011 proposed:

Most urgent and immediate priority is tobacco control Goal for 2040, a world essentially free from tobacco where less than 5% of people use tobacco

WHO has played a pioneer role in developing effective global strategies for tobacco control

Mechanisms for Tobacco Control


Policy
WHO Framework Convention for Tobacco Control (WHO FCTC)
Foundation stone in the global fight against tobacco control Establishes tobacco control as a priority on the public health agenda Introduces a mechanism for country commitment and accountability

Tool
MPOWER: Six policies for tobacco control

Key entry point for scaling up tobacco control Help countries build on WHO FCTC commitments Integral part of the WHO Action Plan for the Prevention and Control of NonCommunicable Diseases

WHO FCTC-MAIN PROVISIONS


Article 6: Price and Tax Measures to reduce the demand for tobacco Article 8: Protection from Exposure to Tobacco Smoke Article 11: Packaging and Labelling of Tobacco Products Article 12: Education, training and communication to raise awareness Article 13: Tobacco Advertising, Promotion and Sponsorship Article 14: Demand Reduction Measures for Tobacco Dependence and Cessation Article 16: Ban on sales to and by minors Article 20: Research, Surveillance and Exchange of Information

The MPOWER package of effective tobacco control measures

r 6 Article policies w Monitor tobacco use and prevention11, 12 Article Protect people from tobacco smoke p e 13 Offer help to quit tobacco 8 Article Article Warn about the dangers of tobacco Enforce bans on advertising and promotion Raise taxes on tobacco o 14 Article

m20 Article

What gets measured gets done


The Parties shall establish, as appropriate, programmes

for national, regional and global surveillance of the magnitude, patterns, determinants, and consequences of tobacco consumption and exposure to tobacco smoke. Towards this end, the Parties should integrate tobacco surveillance programmes into national, regional and global health surveillance programmes so that data are comparable and can be analyzed at the regional and international levels, as appropriate
(Article 20 FCTC)

MPOWER

indicators

monitoring of tobacco use and its key

Public Health Surveillance


Ongoing, systematic

collection, analysis, and


interpretation of healthrelated data essential to the planning,

implementation, and
evaluation of public health practice, with the timely dissemination of these data to those responsible for prevention and

control

Essential activities of surveillance


1. Identify; define and measure the health problem of interest; 2. Collect and compile data about the problem (and if possible, factors that influence it) 3. Analyze and interpret these data 4. Provide these data and their interpretation to those responsible for controlling the health problem and

5. Monitor and periodically evaluate the usefulness and quality of surveillance to improve it for future use

N.B

The key objective of surveillance is to provide information to guide interventions

EXAMPLES OF DATA COLLECTION SYSTEMS FOR SUBSTANCE USE


Alcohol: Global Information System on Alcohol and Health Global Survey on Alcohol and Health Global Status Report on Alcohol and Health

World drug report Depends upon reporting by individual countries which use different survey methodology

No globally active surveillance system for monitoring substance use which uses similar method for collection of data

GLOBAL TOBACCO SURVEILLANCE SYSTEM


Is the most comprehensive surveillance system ever developed, implemented and maintained

Aims to enhance country capacity to design, implement and evaluate tobacco control interventions

GLOBAL TOBACCO SURVEILLANCE SYSTEM


1998- A meeting was convened to discuss the need for collecting data on tobacco use Participants: World Health Organizations Tobacco Free Initiative (WHO TFI) US Centers for Disease Control and Preventions Office on Smoking and Health (CDC OSH) At least one country representative from each of the six WHO Regions Other international agencies, such as UNICEF and the World Bank

GLOBAL TOBACCO SURVEILLANCE SYSTEM


The groups reached consensus on several points: Consistent cross-country data did not exist

Cross-country data for adolescents was a top priority


The surveys should include a core set of questions, identical sampling methodology, and consistent field procedures and data management This meeting paved the way for GTSS in 1998

FUNDAMENTAL PRINCIPLES
Partnership
Consistency Survey methodology Field procedure Data management and processing system Dissemination of data to expand science base Sustainability Cost effective Feasibility to repeat

COMPONENTS
School surveys:
For Youth and Adolescent Global Youth Tobacco survey (GYTS) For adults Global School Personnel Survey (GSPS) Global Health Professions Student Survey (GHPSS)

Household survey:
Global Adult Tobacco Survey (GATS)

PARTNERS
World Health Organization (WHO)
Provide a global policy framework Plan, organize, operationalize, and manage the survey Center for data dissemination Building political commitment across countries

Centre for Disease control and prevention (CDC) provides technical assistance for survey design and sample selection, fieldwork procedures, data management processing and analysis

PARTNERS
Canadian Public Health Association (CPHA)
National Governments Additional Partners for household surveys: Johns Hopkins Bloomberg School of Public Health (JHSPH) RTI International University of North Carolina Survey Research Unit (UNC) Bloomberg Philanthropies

NEED TO TARGET YOUNG POPULATION?


More than 80% of tobacco user initiate before the age of 18 and if young people can remain free of tobacco until age 18, most will never start to smoke Many of the long-term diseases associated with smoking, such as lung cancer, are more likely among those who begin to smoke earlier in life
About 80% will smoke into adulthood and those who persist one-half will die about 13 years earlier than his or her non smoking peers
(U.S.Surgeon General Report 2012)

GYTS
GYTS is a school-based survey of a defined geographic site that can be a country, a province, a city, or any other geographic entity
In March 1999, 11 countries (Barbados, China, Fiji, Jordan, Poland, Russian Federation, South Africa, Sri Lanka, Ukraine, Venezuela, and Zimbabwe) accepted the challenge of pilot testing the first GYTS

All 11 countries completed successful GYTSs during 1999

Currently it has covered >154 WHO Member States 107 countries have conducted a 2nd round 10 countries have conducted a 3rd round

METHODOLOGY
School-based survey of students aged 1315 years
Multistage sample design with schools selected proportional to enrollment size Classrooms chosen randomly within selected schools All students in selected classes eligible for participation Anonymous and confidential self-administered questionnaire

METHODOLOGY
Countries may add questions to the questionnaire
Computer-scannable answer sheets Requires only 3040 minutes to administer Fieldwork conducted in 68 weeks Country-level data with regional-level stratification possible Core questionnaire (standard set of survey questions used in all locations

The core GYTS questionnaire includes 54 questions covering eight categories:


Prevalence of tobacco use Knowledge and attitudes regarding tobacco Second hand smoke exposure

Pro- and anti-tobacco media and advertising exposure


Desire for cessation Access and availability to obtain tobacco School curricula addressing tobacco use and its health effects Demographics

KEY FINDINGS
Values in Percentage

BOYS-Rates: Highest in Europe and Western Pacific Lowest in Eastern Mediterranean and South-East Asia GIRLS-Rates: Highest in Europe and the America Lowest in Eastern Mediterranean and South-East Asia Girls are much less likely to smoke cigarettes than boys in the regions of Africa, Eastern Mediterranean, SouthEast Asia, and Western Pacific Americas girls are more likely than boys to smoke Cigarettes No significant gender differences were observed in the Americas and European region Over 60% of current smoker want to quit smoking

CIGARETTE SMOKING : 1999-2008


21 19 17 14 15 14 12 10 7 5 2 2 8 7 Percentage of Girls who currently smoke cigarettes Percentage of Boys who currently smoke cigarettes

EU R

SE AR

W PR

QUITTING : PERCENTAGE OF STUDENTS WANTING TO QUIT SMOKING 1999-2008


75 53 81 71 63 73 69

Values In Percentages

AFR

AMR

EMR

EUR

TO TA
SEAR

AF

AM

EM

WPR

TOTAL

Rates of other tobacco use is fairly uniform across regions except for Western pacific region
Values In Percentages

TOBACCO USE
14 12 11 7 12 9 8 12 13

In South-East Asia, other tobacco use mainly takes the form of bidis, and in the Eastern Mediterranean, the shisha (waterpipe) is the most prevalent form Use of other tobacco products is greater than cigarette use in the regions of Eastern Mediterranean and South-East Asia

12 8

Percentage of Girls currently using tobacco products other than cigarettes Percentage of Boys currently using tobacco products other than cigarettes

EU R SE AR WP R TO TA L

R AM

AF

EM

Values in Percentage

Exposure to second hand smoke is alarmingly high world wide with highest rates in European region and lowest in African region Over half of the students reported that they had been exposed to second-hand smoke in public places Four in 10 were exposed to smoke in their home Eight in 10 students favor a ban on smoking in public places

SECOND HAND SMOKE : PERCENTAGE OF STUDENTS EXPOSED 1999-2008


86 78 64 55 44 28 41 46 38 49 34 51 55 43 At Home In Public Places

AFR

AMR

EMR

EUR

SEAR

WPR TOTAL

SMOKING BAN : PERCETAGE OF STUDENTS WHO FAVOR A BAN IN PUBLIC PLACES


82 84 83 78 84 78

Values In Percentages

59

AFR

AMR

EMR

EUR

SEAR

WPR

TOTAL

100 80
Percent

60 40 20 0
EURO PAHO SEARO AFRO WPRO EMRO Total

Role of media and advertisements

Saw Anti Message Saw Pro Message on Billboards Saw Pro Message in Newspapers/Magazines

GYTS-INDIA
Initiated in 2003 One of few countries to have conducted 3 rounds of survey 2003, 2006, 2009 2003 survey was conducted state wise whereas in 2006 and 2009 it has been conducted region wise 2009 survey was conducted in >150 schools with >10,000 students participating

KEY FINDINGS
Current use of smoked tobacco was lower in India for both boys and girls (Boys: 12% vs 5.8%, Girls: 7% vs 2.4%) Current use of other forms of tobacco was higher in boys (16.2% vs 12%) and was comparable for girls (8% vs 7.2%) No of students exposed to second hand smoke at home was significantly lower (47% vs 22%) but those exposed to smoke at public places were comparable (48% vs 55 %) About two third of student favored ban smoking at public places and similar no of smokers want to quit which is comparable to world data Three-quarters of the students saw anti-smoking media messages in the past 30 days; three-quarters of the students saw pro-cigarette ads on billboards

GLOBAL

SCHOOL PERSONEL
SURVEY

GSPS
It is a school based survey focused on school personels mainly teachers and administrators
Need to target them:

Act as role models for students


Are conveyors of tobacco-prevention curricula

Are key opinion leaders for school tobacco-control policies

Initiated in 2000

Conducted in 74 WHO Member States 19 countries have conducted a 2nd round of the GSPS

METHODOLOGY
All schools selected for GYTS eligible
All school personnel eligible

Confidential self-administered questionnaire


Names of schools or personnel are not collected and participation is voluntary Surveys are conducted generally at staff meetings or after school

The core GSPS questionnaire includes 45 questions covering five categories:


Prevalence of tobacco use Knowledge and attitudes regarding tobacco School policy School curricula on preventing tobacco use Demographics

KEY FINDINGS
Values In Percentages

CIGARETTES : PERCENTAGE OF SCHOOL TEACHERS AND ADMINISTRATORS WHO CURRENTLY SMOKE CIGATERRES 2000-2008
42 34 30 26 20 16 11 6 2 AFR AMR EMR EUR SEAR WPR TOTAL 18 19 12 8 26 Fem ales Males

Alarming proportion of school personnel smoke cigarettes and use other forms of tobacco Scarcity of tobacco-free schools and the high level of smoking on school grounds by school personnel indicate how seriously school practices and staff actions undermine the educational messages and other prevention efforts to reduce the prevalence of smoking among adolescents

OTHER TOBACCO PRODUCTS : PERCENTAGE OF SCHOOL TEACHERS AND ADMINISTRATORS WHO USE OTHER TOBACCO PRODUCTS 2000-2008
18

Values In Percenatges

16 13 8 5 4 8 4 5 3 13 8 12 Females 7 Males

AFR

AMR

EMR

EUR

SEAR

WPR

TOTAL

BAN ON THE USE OF TOBACCO PRODUCTS

Values In Percentages

Three-quarters of schools ban smoking among students, yet only over half of schools ban smoking among the staff Policies restricting smoking among school personnel must be applied to both students and staff because seeing adults smoking increases the likelihood of regular smoking among students Majority of school personnel have not received specific training to help Students Most teachers reported that they do not have adequate teaching materials

88 78 67 54 38 68 51 66

87 67

85 77 63 56

STAFF BAN : Percentage of schools with a ban on the use of tobacco products by teachers 2000-2008 STUDENT BAN : Percentage of schools with a ban on the use of tobacco products by students 2000-2008

AF R

EU R SE AR

W PR

TRAINING AND MATERIALS


59 44

TO TA

AM

EM

Values In Percentages

40 27 17 12

40 23 16

40

40

Percentage of teachers trained to prevent youth tobacco use 2000-2008

16

19

16

Percentage of teachers with access to materials on how to prevent tobacco use among youth 20002008

EU R SE AR

W PR

TO TA

AF

AM

EM

GSPS-INDIA
Initiated in 2006
2 rounds of survey has been completed 2006 and 2009

In 2009:
School response rate was 98.3%

84.3% of the school personnel completed the survey


2,575 teachers and administrators participated in survey

KEY FINDINGS
One-quarter of school personnel currently use any tobacco product One in 10 currently smoke cigarettes and 17.5% currently use other tobacco products Seven in 10 schools have a policy prohibiting tobacco use among students Nearly twothirds have a policy for personnel Two in 5 schools include tobacco use prevention in school curriculum

KEY FINDINGS
More than one-third of the teachers have access to teaching materials on tobacco use One in 10 teachers has ever received training on youth tobacco use prevention Four in 5 think smoking should be banned from public places Almost 9 in 10 think teacher tobacco use influences youth tobacco use

GLOBAL

HEALTH PROFESSIONS STUDENT


SURVEY

GHPSS
Is a standardized school-based survey of third-year students pursuing advanced degrees in:
Dentistry Medicine Nursing Pharmacy

Is important to collect data on health professionals as they play a key role as service provider in tobacco control
Initiated in 2005

Conducted in 50 who member states 38 countries in dental school, 38 in nursing schools, 49 in medical schools and 33 in pharmacy schools

METHODOLOGY
School-based survey of third-year students in dentistry, medicine, nursing, and pharmacy programs
Can include public and private schools

Sampling possibilities: Multistage sample design with schools selected proportional to enrollment size Classrooms chosen randomly within selected schools or Census of schools and students in countries with few health professional schools
All students in selected classes eligible for participation

KEY FINDINGS

KEY FINDINGS

KEY FINDINGS

GHPSS-INDIA
YEAR NO OF SCHOOLS NO OF OVERALL STUDENT RESPONSE RATE

DENTAL MEDICAL NURSING PHARMACY

2OO5

24

1499

89.4

2006
2007 2008

13
22 25

1177
1082 1428

77.2
92.9 84.8

KEY FINDINGS
1 in 10 health professional smoke cigarette currently and there was no significant gender difference across all 4 disciplines
Use of other tobacco products is significantly less than cigarette smoking ~ 2 in 3 dental and nursing colleges have smoking banned in their premises whereas less then half of medical and pharmacy colleges had such policy In less than half of all colleges smoking ban policy is enforced

KEY FINDINGS
~2 in 3 health professionals currently using tobacco products want to quit but less than half of them have received any advice to quit
More than 50% of all health professional were exposed to second hand smoke at public places ~80% of health professional believe they serve as role models

~ 90% of health professional believe they should receive specific training on cessation techniques but less than 33% have received such training

GLOBAL

ADULT TOBACCO
SURVEY

GATS
Nationally representative household survey of all noninstitutionalized, men and women age 15 years old and older
Initiated in 2007 Sponsors: The Bloomberg Initiative to Reduce Tobacco Use The Bill and Melinda Gates Foundation The U.S. Centers for Disease Control and Prevention World Health Organization

Currently it has been completed in 14 countries

Countries Completed

2nd Phase Countries

METHODOLOGY
Non-institutionalized, men and women age 15 years old and older were included
Three-Stage Cluster Design Stage 1 primary sampling units (PSU) selected probability proportional to size Stage 2 selection of Enumeration Area in each selected PSU Stage 3 selection of Households in each selected EA ONE ELIGIBLE (15+) SELECTED TO PARTICIPATE FROM EACH HOUSEHOLD Residents from all regions of every nation were eligible to be sampled

METHODOLOGY
Minimum sample size of 8000 households was recommended
Face to- face interviews were done in the participants local language Handheld electronic data collection device was used Interviews were done privately Fieldwork was completed within 16 months Ethics review and approval was undertaken

GATS core questionnaire consists of eight sections, each containing multiple questions
Background characteristics Tobacco smoking Smokeless tobacco

Cessation
Second-hand smoke exposure Economics

Media
Knowledge, attitudes and perceptions

GATS-INDIA
Is the project of MOHFW, GOI

IIPS, Mumbai is the nodal implementing agency

Has been conducted in all 29 states and 2 Union Territories, Chandigarh & Pondicherry

he survey covered T 99.92% of Indias population

KEY FINDINGS
275 million tobacco users 197 million males, 78 million females 164 million use smokeless tobacco only Total Males Females

(%)
Tobacco users Smokers (Bidis) Smokeles s tobacco 34.6

(%)
47.9

(%)
20.3

14.0 (9.0) 25.9

24.3 (16.0) 32.9

2.9 (2.0) 18.4

42 million use smoking and smokeless tobacco


Mean age of initiation of tobacco use 17.8 yrs

KEY FINDINGS
Nearly two in five smokers (38%) and users of smokeless tobacco (35%) made an attempt to quit respective tobacco use in the past 12 month
Among 47 percent of smokers who had visited a health care provider in the past 12 months: 53%- were asked if they smoked 46% were advised to stop smoking Among 47 percent of smokeless tobacco users who had visited a health care provider in the past 12 months: 34% were asked whether they used smokeless tobacco 27% were advised to stop such use

KEY FINDINGS
52% of adults were exposed to second-hand smoke (SHS) at home and 30% at outdoor places
51% of who had visited restaurants during past 30 days had seen a designated non-smoking area in the restaurant and 16 percent observed smoking in such an area About 2 in 3 (66%) saw advertisement or promotional message for tobacco products

DATA DISSEMINATION
Website:

www.cdc.gov/tobacco/ global

Fact sheets: one-page document highlighting the countrys survey results Public use data sheets Country reports

Publications:
86 articles in peer-reviewed journals

A GTSS publication is released approximately every 6 weeks

LINKING DATA TO TOBACCO CONTROL POLICIES


High prevalence of tobacco use
Interventions:

Enforce ban on sale of tobacco products to minors


Raising taxes to make tobacco product expensive Require effective package warning labels Implement counter-tobacco advertising Obtain free media coverage of anti-tobacco activities

Pack warnings are effective, especially if they have pictures covering half of pack

More than half changed opinions

2/3 want to quit

3/4 approve of warnings

LINKING DATA TO TOBACCO CONTROL POLICIES


2/3 of tobacco users want to quit
Interventions:

Strengthen health systems so they can make tobacco cessation advice available as part of primary health care
Support quit lines and other community initiatives Easily accessible, lowcost pharmacological treatment where appropriate

LINKING DATA TO TOBACCO CONTROL POLICIES


High rates of exposure to second hand smoke:
Interventions: Enact and enforce completely smoke-free environments in healthcare and educational facilities and in all indoor public places including workplaces, restaurants and bars

LINKING DATA TO TOBACCO CONTROL POLICIES


Role of tobacco industries in promoting tobacco use Intervention:

Enact and enforce effective legislation that comprehensively bans any form of direct tobacco advertising, promotion and sponsorship
Enact and enforce effective legislation to ban indirect tobacco advertising, promotion and sponsorship

LIMITATIONS
Although gyts has extensive coverage other components of GTSS still has to go long way to generate globally comparable data
Data for GTSS are based on the self-report and it might be under-reported or over-reported Limited to students, GYTS is not representative of all youths aged 1315 years GYTS data apply only to youths who were in school on the day of the survey and who completed the survey

LIMITATIONS
GSPS is not an independent sample of schools and is dependent on the success of the GYTS
GHPS-Respondents have not had substantial interaction with patients, survey results cannot not be extrapolated to practicing health professionals Students in all health professions whose members could provide patients with cessation counseling were not surveyed Reliability studies of the GATS core questionnaire items have not been undertaken

FUTURE DIRECTION
GTSS has to further widen its coverage

Provide countries with valuable feedback to evaluate and improve Country National Action Plans and to develop plans where none exist

Examples of countries using GTSS data to enact laws


Seychelles enforced ban on smoking in public places from 2009
Turkey included a provision to mandate broadcasts of antitobacco educational programming during daytime and early evening hours (8:0022:00) in 2003 Venezuela establishes an intergovernmental commission for Tobacco Control in 2006

Philippines: Tobacco Regulatory Act 2003 Regulates the packaging, use, sales distribution, & ads of tobacco products

Build political commitment across countries to spend on tobacco control Policies including monitoring systems

Per capita tobacco tax revenue and Public spending on tobacco control

FUTURE DIRECTION
Continuing to provide data crucial to measure global tobacco epidemic Dissemination of data to build scientific base Establish GYTS, GSPS and GHPS as primary data sources for monitoring FCTC

To be changed...

GTSS JUNE 2009-ATLANTA CELEBRATING 10 YRS

Thank You