Stephen Hamann

Adult smokers' perception of the role of religion and religious leadership on smoking and association with quitting: A comparison between Thai Buddhists and Malaysian Muslims☆

In recent years, attempts have been made to incorporate religion into tobacco control efforts, especially in countries like Malaysia and Thailand where religion is central to the lives of people. This paper is a prospective examination of the perceived relevance and role of religion and religious authorities in influencing smoking behaviour among Muslims in Malaysia and Buddhists in Thailand. Data were collected from 1482 Muslim Malaysian and 1971 Buddhist Thai adult smokers who completed wave 1 (early 2005) of the International Tobacco Control Southeast Asia Survey (ITC-SEA). Respondents were asked about the role of religion and religious leadership on smoking at Wave 1 and among those recontacted, quitting activity at Wave 2. Results revealed that over 90% of both religious groups reported that their religion guides their day-to-day behaviour at least sometimes, but Malaysian Muslims were more likely to report that this was always the case. The majority (79% Muslims and 88% Buddhists) of both groups believed that their religion discourages smoking. About 61% of the Muslims and 58% of the Buddhists reported that their religious leaders had encouraged them to quit before and a minority (30% and 26%, respectively) said they would be an influential source to motivate them to quit. Logistic regression models suggest that these religious factors had a clear independent association with making quitting attempts in both countries and this translated to success for Malaysian Muslims but not for the Thai Buddhists. Taken together, results from this study indicate that religion and religious authorities are both relevant and important drivers of quitting, but whether this is always enough to guarantee success is less clear. Religion can be a culturally relevant vehicle to complement other tobacco control efforts.

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.

Support for and Reported Compliance Among Smokers With Smoke-Free Policies in Air-Conditioned Hospitality Venues in Malaysia and Thailand: Findings From the International Tobacco Control Southeast Asia Survey

This study examined support for and reported compliance with smoke-free policy in air-conditioned restaurants and other similar places among adult smokers in Malaysia and Thailand. Baseline data (early 2005) from the International Tobacco Control Southeast Asia Survey (ITC-SEA), conducted face-to-face in Malaysia and Thailand (n = 4005), were used. Among those attending venues, reported total smoking bans in indoor air-conditioned places such as restaurants, coffee shops, and karaoke lounges were 40% and 57% in Malaysia and Thailand, respectively. Support for a total ban in air-conditioned venues was high and similar for both countries (82% Malaysian and 90% Thai smokers who believed there was a total ban), but self-reported compliance with bans in such venues was significantly higher in Thailand than in Malaysia (95% vs 51%, P < .001). As expected, reporting a ban in air-conditioned venues was associated with a greater support for a ban in such venues in both countries.

Success Counteracting Tobacco Company Interference in Thailand: An Example of FCTC Implementation for Low- and Middle-income Countries

Transnational tobacco companies (TTCs) interfere regularly in policymaking in low- and middle-income countries (LMICs). The WHO Framework Convention for Tobacco Control provides mechanisms and guidance for dealing with TTC interference, but many countries still face ‘how to’ challenges of implementation. For more than two decades, Thailand’s public health community has been developing a system for identifying and counteracting strategies TTCs use to derail, delay and undermine tobacco control policymaking. Consequently, Thailand has already implemented most of the FCTC guidelines for counteracting TTC interference. In this study, our aims are to describe strategies TTCs have used in Thailand to interfere in policymaking, and to examine how the public health community in Thailand has counteracted TTC interference. We analyzed information reported by three groups with a stake in tobacco control policies: Thai tobacco control advocates, TTCs, and international tobacco control experts. To identify TTC viewpoints and strategies, we also extracted information from internal tobacco industry documents. We synthesized these data and identified six core strategies TTCs use to interfere in tobacco control policymaking: (1) doing business with ‘two faces’, (2) seeking to influence people in high places, (3) ‘buying’ advocates in grassroots organizations, (4) putting up a deceptive front, (5) intimidation, and (6) undermining controls on tobacco advertising, promotion and sponsorship. We present three case examples showing where TTCs have employed multiple interference strategies simultaneously, and showing how Thai tobacco control advocates have successfully counteracted those strategies by: (1) conducting vigilant surveillance, (2) excluding tobacco companies from policymaking, (3) restricting tobacco company sales, (4) sustaining pressure, and (5) dedicating resources to the effective enforcement of regulations. Policy implications from this study are that tobacco control advocates in LMICs may be able to develop countermeasures similar to those we identified in Thailand based on FCTC guidelines to limit TTC interference.

Determining the burden of secondhand smoke exposure on the respiratory health of Thai children

BackgroundThe impact of secondhand smoke (SHS) on Southeast Asian children’s health has been assessed by a limited number of studies. The purpose of this study was to determine whether in Thailand, pre- and postnatal exposure to SHS is associated with acute lower respiratory conditions in young children.MethodsWe conducted a case control study of 462 children under age five admitted with acute lower respiratory illnesses, including asthma and pneumonia, at a major hospital in Bangkok. We selected 462 comparison controls from the well-child clinic at the hospital and matched them by sex and age. We used a structured questionnaire to collect information about exposure to SHS and other factors. We conducted bivariate and multivariate analyses to identify risk factors for acute lower respiratory conditions.ResultsThe number of cigarettes smoked at home per day by household members was significantly greater among cases. A greater number of household caregivers of cases held and carried children while smoking as compared to controls (26% versus 7%, p <0.05). Cases were more likely to have been exposed to SHS in the household (adjusted OR = 3.82, 95% CI = 2.47-5.9), and outside (adjusted OR = 2.99, 95% CI = 1.45-6.15). Parental lower educational level and low household income were also associated with respiratory illnesses in Thai children under five.ConclusionsThai children who are exposed to SHS are at nearly 4 times greater risk of developing acute lower respiratory conditions. Continued effort is needed in Thailand to eliminate children’s exposure to SHS, especially at home.

Malaysian and Thai smokers' beliefs about the harmfulness of ‘light’ and menthol cigarettes

Objective This study explored the extent to which Malaysian and Thai smokers believe “light” and menthol cigarettes are less harmful than “regular” cigarettes and the correlates of these beliefs. Methods The study used data from wave 1 of the International Tobacco Control Southeast Asia Survey. 2006 adult smokers (95.3% male) from Malaysia and 2000 adult smokers (94.5% male) from Thailand were interviewed face to face in 2005. Results 29% of Malaysian respondents reported currently smoking light cigarettes and 14% menthols, with 19% agreeing that lights are less harmful and 16% agreeing that menthols are less harmful. 38% of Thai respondents reported currently smoking light cigarettes and 19% menthols, with 46% agreeing that lights are less harmful and 35% agreeing that menthols are less harmful. Malaysian smokers reporting current use of light or menthol cigarettes were more likely to believe that they are less harmful. Reported use of lights did not relate to beliefs for Thai respondents. The belief that light and/or menthol cigarettes are less harmful was strongly related to the belief that they have smoother smoke. Conclusions The experience of smoother smoke is likely to produce some level of belief in reduced harm, regardless of how brands are labelled and whether or not Federal Trade Commission FTC/International Organisation for Standardisation tar, nicotine and carbon monoxide yield figures are used.

Assessment of secondhand smoke in international airports in Thailand, 2013

Objective To assess secondhand smoke (SHS) exposure in Thai international airports using a fine particulate indicator, particulate matter ≤2.5 μm (PM2.5), and to compare with 2012 exposure findings in international airports in the USA. Methods Smoking rooms in the four largest international airports that serve the most travellers and with the most operating designated smoking rooms (DSRs) were monitored using PM2.5 monitoring equipment following an approved research protocol for assessing fine particle pollution from tobacco smoke. Monitoring was conducted inside and just outside DSRs and throughout the airport terminals in all four airports. Altogether 104 samples were taken to assess SHS exposure in four airports. Simultaneous samples were taken multiple times in a total of 11 DSRs available for sampling in the research period. Results Levels of PM2.5 in DSRs were extremely high in all four airports and were more dangerous inside DSRs than in the US airports (overall mean=532.5 vs 188.7 µg/m3), higher outside DSRs than in the US airports (overall mean=50.1 vs 43.7 µg/m3), and at comparable levels with the US airports in the terminals away from DSRs (overall mean=13.8 vs 11.5 µg/m3. Findings show that travellers and employees in or near DSRs in the airports assessed in Thailand are being exposed to even higher levels of SHS than in US airports that still have DSRs. Conclusions Extremely high levels of SHS in and adjacent to DSR show that these rooms are not providing safe air quality for employees and travellers. These high levels of exposure are above those levels reported in US airports and show the need for remedial action to ensure safe air quality in international airports in Thailand.

Building tobacco control research in Thailand: meeting the need for innovative change in Asia

IntroductionIn low- and middle-income countries (LMICs) over the past two decades locally relevant tobacco control research has been scant. Experience shows that tobacco control measures should be based on sound research findings to ensure that measures are appropriate for local conditions and that they are likely to have an impact. Research should also be integrated within tobacco control measures to ensure ongoing learning and the production of knowledge. Thailand, a middle-income country, has a public health community with a record of successful tobacco control and a longstanding commitment to research. Thailands comprehensive approach includes taxation; bans on tobacco advertising, sponsorship and promotion; smoke-free areas; graphic cigarette pack warnings; social marketing campaigns; cessation counseling; and an established tobacco control research program. The purpose of this study was to document and analyze the development of tobacco control research capacity in Thailand and the impact of research on Thai tobacco control measures.MethodWe used mixed methods including review of historical documentation and policy reports, qualitative interviews with key members of Thailands tobacco control community, and an analysis of research productivity.FindingsIn Thailand, tobacco control research has evolved through three phases: (1) discovery of the value of research in the policymaking arena, (2) development of a structure to support research capacity building through international collaborations supported by foreign funding agencies, and (3) delivery of locally relevant research made possible largely through substantial stable funding from a domestic health promotion foundation. Over two decades, Thai tobacco control advocates have constructed five steppingstones to success: (1) adapting foreign research to inform policymaking and lobbying for more support for domestic research; (2) attracting foreign funding agencies to support small-scale research and capacity building; (3) participating in multi-country research and capacity building programs; (4) using collaborative experiences to demonstrate the need for domestic support of locally relevant research; and (5) maintaining an unwavering commitment to research while being vigilant to ensure continued research support.ConclusionThe evolution of tobacco control research in Thailand provides examples of steppingstones that LMICs may be able to use to construct their own tobacco control research pathways.

The leadership challenge of tobacco use in Asia: towards health promotion and health for all.

Tobacco use in Asia is sharply on the rise. Present trends in increased smoking behavior will result in epidemics of smoking related diseases and deaths of millions annually in the foreseeable future. Collective leadership for health from several sectors is needed to reverse the trend in increased tobacco use. An agenda for action by leaders is presented, and an intersectoral approach is advocated with a focus on proactive measures to promote positive behaviors for health and to prevent a pandemic of unprecedented proportions.

Impact of Point-of-Sale Tobacco Display Bans in Thailand: Findings from the International Tobacco Control (ITC) Southeast Asia Survey

In September 2005 Thailand became the first Asian country to implement a complete ban on the display of cigarettes and other tobacco products at point-of-sale (POS). This paper examined the impact of the POS tobacco display ban in Thailand, with Malaysia (which did not impose bans) serving as a comparison. The data came from the International Tobacco Control Southeast Asia Survey (2005–2011), a prospective cohort survey designed to evaluate the psychosocial and behavioral impacts of tobacco control policies. Main measures included smokers’ reported awareness of tobacco displays and advertising at POS. At the first post-ban survey wave over 90% of smokers in Thailand were aware of the display ban policy and supported it, and about three quarters thought the ban was effective. Noticing tobacco displays in stores was lowest (16.9%) at the first post-ban survey wave, but increased at later survey waves; however, the levels were consistently lower than those in Malaysia. Similarly, exposure to POS tobacco advertising was lower in Thailand. The display ban has reduced exposure to tobacco marketing at POS. The trend toward increased noticing is likely at least in part due to some increase in violations of the display bans and/or strategies to circumvent them.