title: Tobacco control environment: cross-sectional survey of policy implementation, social unacceptability, knowledge of tobacco health harms and relationship to quit ratio in 17 low-income, middle-income and high-income countries.
abstract: This study examines in a cross-sectional study 'the tobacco control environment' including tobacco policy implementation and its association with quit ratio.
  
  
  
  545 communities from 17 high-income, upper-middle, low-middle and low-income countries (HIC, UMIC, LMIC, LIC) involved in the Environmental Profile of a Community's Health (EPOCH) study from 2009 to 2014.
  
  
  
  Community audits and surveys of adults (35-70 years, n=12 953).
  
  
  
  Summary scores of tobacco policy implementation (cost and availability of cigarettes, tobacco advertising, antismoking signage), social unacceptability and knowledge were associated with quit ratios (former vs ever smokers) using multilevel logistic regression models.
  
  
  
  Average tobacco control policy score was greater in communities from HIC. Overall 56.1% (306/545) of communities had >2 outlets selling cigarettes and in 28.6% (154/539) there was access to cheap cigarettes (<5cents/cigarette) (3.2% (3/93) in HIC, 0% UMIC, 52.6% (90/171) LMIC and 40.4% (61/151) in LIC). Effective bans (no tobacco advertisements) were in 63.0% (341/541) of communities (81.7% HIC, 52.8% UMIC, 65.1% LMIC and 57.6% LIC). In 70.4% (379/538) of communities, >80% of participants disapproved youth smoking (95.7% HIC, 57.6% UMIC, 76.3% LMIC and 58.9% LIC). The average knowledge score was >80% in 48.4% of communities (94.6% HIC, 53.6% UMIC, 31.8% LMIC and 35.1% LIC). Summary scores of policy implementation, social unacceptability and knowledge were positively and significantly associated with quit ratio and the associations varied by gender, for example, communities in the highest quintile of the combined scores had 5.0 times the quit ratio in men (Odds ratio (OR) 5·0, 95% CI 3.4 to 7.4) and 4.1 times the quit ratio in women (OR 4.1, 95% CI 2.4 to 7.1).
  
  
  
  This study suggests that more focus is needed on ensuring the tobacco control policy is actually implemented, particularly in LMICs. The gender-related differences in associations of policy, social unacceptability and knowledge suggest that different strategies to promoting quitting may need to be implemented in men compared to women.
authors.affiliation: Department of Cardiology, Westmead Hospital and The George Institute, University of Sydney, Camperdown, New South Wales, Australia.|Population Health Research Institute(PHRI), Hamilton, Ontario, Canada.
authors.forename: Clara K
authors.identifier: 0000-0003-4693-0038
authors.initials: CK
authors.lastname: Chow
authors.affiliation: Department of Cardiology, Westmead Hospital and The George Institute, University of Sydney, Camperdown, New South Wales, Australia.|Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Corsi
authors.affiliation: Tobacco Control Research Group, Department for Health, University of Bath, Bath, UK.
authors.forename: Anna B
authors.initials: AB
authors.lastname: Gilmore
authors.affiliation: Faculty of Health Science North, West University Potchefstroom Campus, Potchefstroom, South Africa.
authors.forename: Annamarie
authors.initials: A
authors.lastname: Kruger
authors.affiliation: School of Public Health, University of the Western Cape, Bellville, South Africa.
authors.forename: Ehimario
authors.initials: E
authors.lastname: Igumbor
authors.affiliation: Physiology Department, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.
authors.forename: Jephat
authors.initials: J
authors.lastname: Chifamba
authors.affiliation: National Center for Cardiovascular Diseases, Beijing, China.
authors.forename: Wang
authors.initials: W
authors.lastname: Yang
authors.affiliation: National Center for Cardiovascular Diseases Cardiovascular Institute & Fuwai Hospital Chinese Academy of Medical Sciences, Beijing, China.
authors.forename: Li
authors.initials: L
authors.lastname: Wei
authors.affiliation: Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan.
authors.forename: Romaina
authors.initials: R
authors.lastname: Iqbal
authors.affiliation: Division of Epidemiology & Population Health, St John's Medical College & Research Institute, Bangalore, Karnataka, India.
authors.forename: Prem
authors.initials: P
authors.lastname: Mony
authors.affiliation: Fortis Escorts Hospital, Jaipur, Rajasthan, India.
authors.forename: Rajeev
authors.initials: R
authors.lastname: Gupta
authors.affiliation: Department of Community Medicine, Dr Somervell Memorial CSI Medical College, Karakonam, Thiruvananthapuram, Kerala, India.
authors.forename: Krishnapillai
authors.initials: K
authors.lastname: Vijayakumar
authors.affiliation: Madras Diabetes Research Foundation, Chennai, India.
authors.forename: V
authors.initials: V
authors.lastname: Mohan
authors.affiliation: PGIMER School of Public Health, Chandigarh, India.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Kumar
authors.affiliation: Independent University, Bangladesh Bashundhara, Dhaka, Bangladesh.
authors.forename: Omar
authors.initials: O
authors.lastname: Rahman
authors.affiliation: Universiti Teknologi MARA Sungai Buloh, Selangor, Malaysia UCSI University, Cheras, Malaysia.
authors.forename: Khalid
authors.initials: K
authors.lastname: Yusoff
authors.affiliation: Department of Community Health, University Kebangsaan Malaysia Medical Centre, Bangi, Malaysia.
authors.forename: Noorhassim
authors.initials: N
authors.lastname: Ismail
authors.affiliation: Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland.
authors.forename: Katarzyna
authors.initials: K
authors.lastname: Zatonska
authors.affiliation: Sisli Etfal Teaching and Research Hospital, Istanbul, Turkey.
authors.forename: Yuksel
authors.initials: Y
authors.lastname: Altuntas
authors.affiliation: Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden.
authors.forename: Annika
authors.initials: A
authors.lastname: Rosengren
authors.affiliation: Hypertension Research Center Isfahan Cardiovascular Research Center Isfahan University of Medical Sciences, Isfahan, Iran.
authors.forename: Ahmad
authors.initials: A
authors.lastname: Bahonar
authors.affiliation: Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates.
authors.forename: AfzalHussein
authors.initials: A
authors.lastname: Yusufali
authors.affiliation: Institut universitaire de cardiologie et pneumologie de Québec, Université laval,Quebec, Quebec, Montreal, Canada.
authors.forename: Gilles
authors.initials: G
authors.lastname: Dagenais
authors.affiliation: Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.
authors.forename: Scott
authors.initials: S
authors.lastname: Lear
authors.affiliation: Estudios Clinicos Latinoamerica ECLA, Rosario, Argentina.
authors.forename: Rafael
authors.initials: R
authors.lastname: Diaz
authors.affiliation: Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil.
authors.forename: Alvaro
authors.initials: A
authors.lastname: Avezum
authors.affiliation: Fundacion Oftalmologica de Santander (FOSCAL), Floridablanca-Santander, Colombia.
authors.forename: Patricio
authors.initials: P
authors.lastname: Lopez-Jaramillo
authors.affiliation: Universidad de La Frontera, Temuco, Chile.
authors.forename: Fernando
authors.initials: F
authors.lastname: Lanas
authors.affiliation: Population Health Research Institute(PHRI), Hamilton, Ontario, Canada.
authors.forename: Sumathy
authors.initials: S
authors.lastname: Rangarajan
authors.affiliation: Population Health Research Institute(PHRI), Hamilton, Ontario, Canada.
authors.forename: Koon
authors.initials: K
authors.lastname: Teo
authors.affiliation: London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Martin
authors.initials: M
authors.lastname: McKee
authors.affiliation: Population Health Research Institute(PHRI), Hamilton, Ontario, Canada.
authors.forename: Salim
authors.initials: S
authors.lastname: Yusuf
mesh_terms: D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D019049:Developed Countries; D003906:Developing Countries; D004777:Environment; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006291:Health Policy; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010342:Patient Acceptance of Health Care; D012907:Smoking / Q000009:adverse effects / Q000628:therapy; D016540:Smoking Cessation; D011795:Surveys and Questionnaires; D062789:Tobacco Products; D000073869:Tobacco Smoking / Q000009:adverse effects / Q000628:therapy*
keywords: Knowledge of tobacco harms; Social unacceptability; Tobacco control policy; Tobacco environment