Anne C. K. Quah

Perceptions of tobacco health warnings in China compared with picture and text-only health warnings from other countries: an experimental study.

Objective To assess the perceived effectiveness of cigarette health warnings in China, compared with picture and text-only warnings from other countries. Method 1169 individuals (adult smokers, adult nonsmokers and youth) from four Chinese cities (Beijing, Shanghai, Kunming and Yinchuan) viewed 10 health warnings on cigarette packages, which included (a) the current Chinese text warnings covering 30% of the front/back of the pack (introduced October 2008); (b) the former Chinese text warning located on the side of the pack; (c) four picture warnings covering 50% of the front/back of the pack from Canada (lung cancer), Singapore (mouth disease), Hong Kong (gangrene) and European Union (clogged arteries); and (d) the same four warnings without the picture. Participants rated and ranked the 10 warnings on dimensions including how effective each would be in motivating smokers to quit and in convincing youth not to start smoking. Results Both Chinese warnings were consistently rated as least effective, with the new Chinese warning rated only slightly higher than the old warning. The picture warnings were consistently ranked or rated as most effective, with the text-only versions in the middle. Results were consistent across subject group, city and sex. Conclusions (1) Picture warnings are rated as much more effective than the same warnings without pictures. (2) The revised health warnings in China, introduced in October 2008, are only marginally more effective than the previous warning and far less effective than even text warnings from other countries. These results, coupled with population-based evaluation studies, suggest that pictorial warnings would significantly increase the impact of health warnings in China.

Predictors of smoking cessation among adult smokers in Malaysia and Thailand: findings from the International Tobacco Control Southeast Asia Survey.

INTRODUCTION Limited longitudinal studies on smoking cessation have been reported in Asia, and it remains unclear whether determinants of quitting are similar to those found in Western countries. This study examined prospective predictors of smoking cessation among adult smokers in Thailand and Malaysia. METHODS Four thousand and four smokers were surveyed in Malaysia and Thailand in 2005. Of these, 2,426 smokers were followed up in 2006 (61% retention). Baseline measures of sociodemographics, dependence, and interest in quitting were used to predict both making quit attempts and point prevalence maintenance of cessation. RESULTS More Thai than Malaysian smokers reported having made quit attempts between waves, but among those who tried, the rates of staying quit were not considerably different between Malaysians and Thais. Multivariate analyses showed that smoking fewer cigarettes per day, higher levels of self-efficacy, and more immediate quitting intentions were predictive of both making a quit attempt and staying quit in both countries. Previous shorter quit attempts and higher health concerns about smoking were only predictive of making an attempt, whereas prior abstinence for 6 months or more and older age were associated with maintenance. DISCUSSION In Malaysia and Thailand, predictors of quitting activity appear to be similar. However, as in the West, predictors of making quit attempts are not all the same as those who predict maintenance. The actual predictors differ in potentially important ways from those found in the West. We need to determine the relative contributions of cultural factors and the shorter history of efforts to encourage quitting in Asia.

Adult Smokers’ Reactions to Pictorial Health Warning Labels on Cigarette Packs in Thailand and Moderating Effects of Type of Cigarette Smoked: Findings From the International Tobacco Control Southeast Asia Survey

Introduction: In this study, we aimed to examine, in Thailand, the impact on smokers’ reported awareness of and their cognitive and behavioral reactions following the change from text-only to pictorial warnings printed on cigarette packs. We also sought to explore differences by type of cigarette smoked (roll-your-own [RYO] vs. factory-made [FM] cigarettes). Methods: Data came from the International Tobacco Control Southeast Asia Survey, conducted in Thailand and Malaysia, where a representative sample of 2,000 adult smokers from each country were recruited and followed up. We analyzed data from one wave before (Wave 1) and two waves after the implementation of the new pictorial warnings (two sets introduced at Waves 2 and 3, respectively) in Thailand, with Malaysia, having text-only warnings, serving as a control. Results: Following the warning label change in Thailand, smokers’ reported awareness and their cognitive and behavioral reactions increased markedly, with the cognitive and behavioral effects sustained at the next follow-up. By contrast, no significant change was observed in Malaysia over the same period. Compared to smokers who smoke any FM cigarettes, smokers of only RYO cigarettes reported a lower salience but greater cognitive reactions to the new pictorial warnings. Conclusions: The new Thai pictorial health warning labels have led to a greater impact than the text-only warning labels, and refreshing the pictorial images may have helped sustain effects. This finding provides strong support for introducing pictorial warning labels in low- and middle-income countries, where the benefits may be even greater, given the lower literacy rates and generally lower levels of readily available health information on the risks of smoking.

Socioeconomic Differences in Exposure to Tobacco Smoke Pollution (TSP) in Bangladeshi Households with Children: Findings from the International Tobacco Control (ITC) Bangladesh Survey

This study assessed the pattern of exposure to tobacco smoke pollution (TSP; also known as, secondhand smoke) in Bangladeshi households with children and examined the variations in household smoking restrictions and perception of risk for children’s exposure to TSP by socioeconomic status. We interviewed 1,947 respondents from Bangladeshi households with children from the first wave (2009) of the International Tobacco Control (ITC) Bangladesh Survey. 43.5% of the respondents had complete smoking restrictions at home and 39.7% were very or extremely concerned about TSP risk to children’s health. Participants with lower level of education were significantly less likely to be concerned about the risk of TSP exposure to children’s health and less likely to adopt complete smoking restrictions at home. Logistic regression revealed that the predictors of concern for TSP exposure risk were educational attainment of 1 to 8 years (OR = 1.94) or 9 years or more (OR = 4.07) and being a smoker (OR = 0.24). The predictors of having complete household smoking restrictions were: urban residence (OR = 1.64), attaining education of 9 years or more (OR = 1.94), being a smoker (OR = 0.40) and being concerned about TSP exposure risk to children (OR = 3.25). The findings show that a high proportion of adults with children at home smoke tobacco at home and their perceptions of risk about TSP exposure to children’s health were low. These behaviours were more prevalent among rural smokers who were illiterate. There is a need for targeted intervention, customized for low educated public, on TSP risk to children’s health and tobacco control policy with specific focus on smoke-free home.

Knowledge of Health Effects and Intentions to Quit Among Smokers in India: Findings From the Tobacco Control Policy (TCP) India Pilot Survey

Awareness of the health risks of smoking is an important factor in predicting smoking-related behaviour; however, little is known about the knowledge of health risks in low-income countries such as India. The present study examined beliefs about the harms of smoking and the impact of health knowledge on intentions to quit among a sample of 249 current smokers in both urban and rural areas in two states (Maharashtra and Bihar) from the 2006 TCP India Pilot Survey, conducted by the ITC Project. The overall awareness among smokers in India of the specific health risks of smoking was very low compared to other ITC countries, and only 10% of respondents reported that they had plans to quit in the next six months. In addition, smokers with higher knowledge were significantly more likely to have plans to quit smoking. For example, 26.2% of respondents who believed that smoking cause CHD and only 5.5% who did not believe that smoking causes CHD had intentions to quit (χ2 = 16.348, p < 0.001). Important differences were also found according to socioeconomic factors and state: higher levels of knowledge were found in Maharashtra than in Bihar, in urban compared to rural areas, among males, and among smokers with higher education. These findings highlight the need to increase awareness about the health risks of smoking in India, particularly in rural areas, where levels of education and health knowledge are lower.

Using cognitive interviewing and behavioral coding to determine measurement equivalence across linguistic and cultural groups: An example from the international tobacco control policy evaluation project

This study examined and compared results from two questionnaire pretesting methods (i.e., behavioral coding and cognitive interviewing [CI]) to assess systematic measurement bias in survey questions for adult smokers across six countries (United States, Australia, Uruguay, Mexico, Malaysia, and Thailand). Protocol development and translation involved multiple bilingual partners in each linguistic/cultural group. The study was conducted with convenience samples of 20 adult smokers in each country. Behavioral coding and CI methods produced similar conclusions regarding measurement bias for some questions; however, CI was more likely to identify potential response errors than behavioral coding. Coordinated qualitative pretesting of survey questions (or postsurvey evaluation) is feasible across cultural groups and can provide important information on comprehension and comparability. The CI appears to be a more robust technique than behavioral coding, although combinations of the two might be even better.

Correlates of exposure to secondhand smoke (SHS) at home among non-smoking adults in Bangladesh: findings from the ITC Bangladesh survey

BackgroundExposure to secondhand smoke (SHS) is a serious global public health problem. Understanding the correlates of SHS exposure could guide the development of evidence based SHS exposure reduction interventions. The purpose of this study is to describe the pattern of and factors associated with SHS exposure among non-smoking adults in Bangladesh.MethodsData come from adult non-smokers who participated in the second wave (2010) of the International Tobacco Control Policy (ITC) Evaluation Bangladesh Survey conducted in all six administrative divisions of Bangladesh. A structured questionnaire gathered information on participants’ demographic characteristics, pattern of SHS exposure, SHS knowledge, and attitudes towards tobacco control. Exposure to SHS at home was defined as non-smokers who lived with at least one smoker in their household and who reported having no home smoking ban. The data were analyzed using chi-square tests and logistic regression procedures.ResultsThe SHS exposure rate at home among the participants (N = 2813) was 43%. Several sociodemographic and attitudinal factors were associated with SHS exposure. Logistic regression analyses identified eight predictors of SHS exposure: being female (OR = 2.35), being aged 15–24 (OR = 2.17), being recruited from Dhaka slums (OR = 5.19) or non-tribal/non-border areas outside Dhaka (OR = 2.19) or tribal/border area (OR = 4.36), having lower education (1–8 years: OR = 2.45; illiterate: OR = 3.00, having higher monthly household income (5000 to <10,000 Taka: OR = 2.34; 10,000 Taka or more: OR = 2.28), having a father who smoked in the past or currently smokes (OR = 2.09), having lower concern about the harms of tobacco on children (unconcerned OR = 3.99; moderate concern OR = 2.26), and not knowing the fact that SHS causes lung cancer in non-smokers (OR = 2.04).ConclusionsAlmost half of non-smoking Bangladeshi adults are exposed to SHS at home. The findings suggest the need for comprehensive tobacco control measures that would improve public understanding about health hazards of SHS exposure at home and encourage educational initiatives to promote smoke-free homes. Interventions should deliver targeted messages to reach those in the low socioeconomic status group.

Prevalence and Patterns of Tobacco Use in Bangladesh from 2009 to 2012: Evidence from International Tobacco Control (ITC) Study.

Background Smoking and passive smoking are collectively the biggest preventable cause of death in Bangladesh, with major public health burden of morbidity, disability, mortality and community costs. The available studies of tobacco use in Bangladesh, however, do not necessarily employ nationally representative samples needed to monitor the problem at a national scale. This paper examines the prevalence and patterns of tobacco use among adults in Bangladesh and the changes over time using large nationally representative comparable surveys. Methods Using data from two enumerations of the International Tobacco Control (ITC) Bangladesh Project conducted in 2009 and 2012, prevalence estimates are obtained for all tobacco products by socio-economic determinants and sample types of over 90,000 individuals drawn from over 30,000 households. Household level sample weights are used to obtain nationally representative prevalence estimates and standard errors. Statistical tests of difference in the estimates between two time periods are based on a logistic regression model that accounts for the complex sampling design. Using a multinomial logit model, the time trend in tobacco use status is identified to capture the effects of macro level determinants including changes in tobacco control policies. Results Between 2009 and 2012, overall tobacco use went down from 42.4% to 36.3%. The decline is more pronounced with respect to smokeless tobacco use than smoking. The prevalence of exclusive cigarette smoking went up from 7.2% to 10.6%; exclusive bidi smoking remained stable at around 2%; while smoking both cigarette and bidi went down from 4.6% to 1.8%; exclusive smokeless tobacco use went down from 20.2% to 16.9%; and both smokeless tobacco use and smoking went down from 8.4% to 5.1%. In general, the prevalence of tobacco use is higher among men, increases from younger to older age groups, and is higher among poorer people. Smoking prevalence is the highest among the slum population, followed by the tribal population, the national population and the border area population, suggesting greater burden of tobacco use among the disadvantaged groups. Conclusions The overall decline in tobacco use can be viewed as a structural shift in the tobacco market in Bangladesh from low value products such as bidi and smokeless tobacco to high value cigarettes, which is expected with the growth in income and purchasing power of the general population. Despite the reduction in overall tobacco use, the male smoking prevalence in Bangladesh is still high at 37%. The world average of daily smoking among men is 31.1%. The Tobacco Control Act 2005 and the Amendment have yet to make a significant impact in curbing tobacco usage in Bangladesh. The findings in this paper further suggest that the tobacco control policies in Bangladesh need to include targeted interventions to restrain the use of particular types of tobacco products among specific demographic and socio-economic groups of the population, such as smoked tobacco among men, smokeless tobacco among women, and both smoked and smokeless tobacco among those living in rural areas, those in low socio-economic status and those belonging to the tribal and the slum population.

When a tax increase fails as a tobacco control policy: the ITC China project evaluation of the 2009 cigarette tax increase in China.

China ratified the WHO Framework Convention on Tobacco Control (the WHO FCTC) in 2006 and thus has the obligation to increase the prices and taxes of cigarettes. In May 2009, China raised cigarette excise taxes, which was cited by a Chinese government official as a measure of FCTC implementation.1 Researchers noticed that cigarette retail prices in China did not change after the 2009 tax adjustment; however, their conclusion was based on observations but not survey data.2 We used …

The lower effectiveness of text-only health warnings in China compared to pictorial health warnings in Malaysia

Background In 2009, China changed its health warnings on cigarette packs from side-only text warnings to two text-only warnings on 30% of the bottom of the front and back of the pack. Also in 2009, Malaysia changed from similar text warnings to pictorial health warnings consistent with Framework Convention on Tobacco Control (FCTC) Article 11 Guidelines. Objective To measure the impact of the change in health warnings in China and to compare the text-only health warnings to the impact of the pictorial health warnings introduced in Malaysia. Methods We measured changes in key indicators of warning effectiveness among a longitudinal cohort sample of smokers from Waves 1 to 3 (2006–2009) of the International Tobacco Control (ITC) China Survey and from Waves 3 to 4 (2008–2009) of the ITC Malaysia Survey. Each cohort consisted of representative samples of adult (≥18 years) smokers from six cities in China (n=6575) and from a national sample in Malaysia (n=2883). Generalised Estimating Equations (GEE) were used to examine the impact of the health warnings on subsequent changes in salience of warnings, cognitive and behavioural outcomes. Findings Compared to Malaysia, the weak text-only warning labels in China led to a significant change in only two of six key indicators of health warning effectiveness: forgoing cigarettes and reading the warning labels. The change to pictorial health warnings in Malaysia led to significant and substantial increases in five of six indicators (noticing, reading, forgoing, avoiding, thinking about quitting). Conclusions The delay in implementing pictorial health warnings in China constitutes a lost opportunity for increasing knowledge and awareness of the harms of cigarettes, and for motivating smokers to quit.