Regional Strategy for Utilization of Tobacco Questions for Surveys (TQS)
SEA-Tobacco-46 Distribution: General
Regional Strategy for Utilization of Tobacco Questions for Surveys (TQS)
© World Health Organization 2012
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Contents Page
1. Background .................................................................................................... 1 2. Objective........................................................................................................ 3 3. Challenges ...................................................................................................... 5 4. Targets............................................................................................................ 5 5. Strategies ........................................................................................................ 6 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 Support to formulation of national tobacco control policy and plan of action and enforcement of national legislation........................... 6 Increasing knowledge on the hazards of tobacco among schoolchildren ...................................................................................... 7 Protection from second-hand smoke..................................................... 7 Ban on advertisement of tobacco products ........................................... 7 Limiting access to tobacco products ...................................................... 8 Tax policies........................................................................................... 9 Cessation of tobacco use..................................................................... 10 Surveillance and monitoring of tobacco control activities .................... 10 Identification and mobilization of financial resources .......................... 10
5.10 Promoting partnerships for tobacco control ......................................... 11
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1.
Background Member States in WHO’s South-East Asia Region are home to 250 million tobacco smokers and an equal number of smokeless tobacco users. Ninety per cent of global smokeless tobacco users live in this Region. Ten of the 11 Member States in the Region have ratified the WHO Framework Convention on Tobacco Control (WHO FCTC). Under Article 5 (General obligations) of the WHO FCTC, Member States who are Party to the Convention shall develop, implement, periodically update and review comprehensive multisectoral national tobacco control strategies, plans and programmes. One of the essential components of a comprehensive tobacco control effort is an efficient and systematic surveillance mechanism to monitor the epidemic as envisaged in Article 20 (Research, surveillance and exchange of information) of the Convention. The Framework Convention on Tobacco Control has been ratified by 174 Member States. Under Article 21 (reporting and exchange of information) of the WHO FCTC, Member States as Parties are required to provide a progress report on the implementation of the Convention after every two years. WHO’s report on the Global Tobacco Epidemic is published every two years which also examines the periodicity of monitoring and gives scoring (M scoring). The Global Adult Tobacco Survey (GATS) was developed to meet this need by generating comparable data within and across countries. The survey questions in this guide are taken from the GATS questionnaire. GATS was developed to provide a global standard protocol for consistent monitoring of adult tobacco use. GATS is designed to produce national and sub-national estimates on tobacco use, exposure to second-hand smoke, and quit attempts among adults across countries and indirectly measure the impact of tobacco control and prevention initiatives. GATS is intended to assist countries to design, implement and evaluate tobacco control and prevention programmes. GATS is a nationally representative household survey of all noninstitutionalized men and women aged 15 years and older; and uses a
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Regional Strategy for Utilization of Tobacco Questions for Surveys (TQS)
standard and consistent core questionnaire, sample design, and data collection and management techniques that were reviewed and approved by the review committees comprised of experts from developed and developing countries. The GATS Core Questionnaire was constructed by tobacco control and survey design experts and has undergone rigorous development and testing. GATS was conducted in 14 countries in the first phase including Bangladesh, India and Thailand in the Region. In the second phase, GATS was conducted in Indonesia and repeated in Thailand. In order to maintain consistency and comparability in monitoring tobacco use, a standard set of survey questions on tobacco use should be implemented across various surveys, and should be periodically monitored. Given this important need, GATS partners have created the Tobacco Questions for Surveys booklet which includes a subset of key survey questions from GATS for other surveys to include. Surveys can select indicators and corresponding questions from this list to include based on their particular focus or priority, or incorporate the complete set if appropriate. The Tobacco Questions for Survey (TQS) have been developed for countries that are not implementing full GATS and for surveys that want to include questions on tobacco. This guide includes a recommended subset of key GATS questions that can be used as a standalone module or included in existing surveys. Surveys using the questions and response categories from TQS will help to improve survey comparability over time and harmonize them with international tobacco surveillance and monitoring activities. TQS guide: Explains why it is important to adopt a standard set of tobacco questions in surveys. Introduces the set of questions on tobacco corresponding analysis indicators including: – – and the
tobacco smoking prevalence questions which are essential in monitoring smoking rates; additional questions covering key aspects of tobacco use and policies.
Provides definitions and instructions for administering the questions. Explains how survey data from the questions are used to estimate key tobacco indicators.
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Regional Strategy for Utilization of Tobacco Questions for Surveys (TQS)
TQS implementation in SEA Region: The following are some recent examples of how TQS has been used in the Region. Questions with response categories on exposure to second hand smoke and knowledge and awareness from TQS have been used in Myanmar STEPS NCD risk factor survey (STEPS). Maldives has used all questions from TQS with STEPS in 2011. Thailand’s National Statistical Office (NSO) annual survey on smoking and drinking behaviour has also used questions from TQS.
2.
Objective General: To monitor implementation of WHO FCTC in a periodic, consistent and cost-effective manner. Specific: The South-East Asia Regional Strategy for utilization of TQS aims to provide guidance, coordination and support to Member States to: (1) Formulate, promote and implement their national tobacco control policies and plans of action which incorporate consistent data related to tobacco use prevalence among adults and utilization of this data for improving tobacco control efforts. Prepare them in reporting consistent data related to tobacco use prevalence among adults every two years to the COP secretariat. Help reduce tobacco use among adults by applying tobacco control efforts in line with WHO FCTC. Enhance awareness on the dangers of tobacco use among adults by enhancing education, training, communication and advocacy through wider media coverage and all other possible means. Promote awareness on the dangers of exposure to second-hand smoke and to protect the adult population from exposure to second-hand smoke by taking measures to ban smoking in all public places, work places and in public transport. Ban all forms of tobacco advertisement, promotion and sponsorship. Implement counter-marketing measures against the tobacco industry to prevent the population from falling prey to the lure of the industry.
(2) (3) (4)
(5)
(6) (7)
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Regional Strategy for Utilization of Tobacco Questions for Surveys (TQS)
(8) (9)
Establish appropriate tax and price measures which aim at prevention of initiation of tobacco use. Implement measures to promote cessation of tobacco use for adults especially among disadvantaged groups.
(10) Develop, enact, promulgate, implement and enforce comprehensive national tobacco control legislation, as appropriate, in line with WHO FCTC. Sources of adult tobacco use prevalence data: Sources of adult tobacco use prevalence and other tobacco control indicators data in the Region are Demographic Health Survey (DHS), NCD Risk Factor survey, Behavioural Risk Factor Survey (BRFS), National Statistical Office (NSO) Surveys (yearly survey, Sample Registration System) and Global Adult Tobacco Survey (GATS). Surveys other than GATS have limitations of indicator information. DHS provides information on reproductive age group and tobacco use prevalence only. STEPS use 25+ age groups. Information on tobacco use prevalence is only available from most of the reports. National Sample Survey Organization (India) and SUSENAS (Indonesia) has information on household expenditure on tobacco. Global Adult Tobacco Survey questionnaire and TQS cover comprehensively Articles 20-22 (tobacco smoking, smokeless tobacco use), Article 8 (second-hand smoke), Article 14 (tobacco cessation), Article 12 (knowledge and awareness), Article 11 (packaging and labeling), Article 13 (advertisement) and Article 6 (economics-expenditure on tobacco). Opportunity: TQS provides a unique opportunity to Member States to obtain tobacco control indicators in a cost-effective, consistent and sustainable manner by integrating standard tobacco questions from TQS in their regular surveys such as the census or in sample registration system surveillance, annual surveys conducted by the National Statistical Office on various topics such as social factors, household expenditure, DHS, STEPS and any other surveys. Bangladesh, India and Indonesia may repeat GATS/ stand-alone or with any ongoing survey. India may use questions with response categories from TQS in the annual health survey and district-level health survey. Indonesia may use questions with response categories from TQS in SUSENAS.
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Regional Strategy for Utilization of Tobacco Questions for Surveys (TQS)
3.
Challenges Some minor challenges are mentioned below: Technical: Adding more questions in any survey may increase the burden on respondents. However, these can be overcome by balancing the number of questions according to the need of the country and by using electronic handheld techniques to minimize the respondents’ time. Administrative: National statistical offices are under other ministries. Hence coordination between health and other ministries is required.
4.
Targets The targets of the Regional Strategy would be to support Member States to: (1) Have comprehensive, sustainable and accountable national policies and strategies for utilization of adult data by using TQS for tobacco control in all Member States. Streamline national tobacco control legislation in all countries of the Region based on the provisions of WHO FCTC utilizing the data used from TQS. The legislation will include measures to protect the adult population from the lure of the tobacco industry. Have all health and education facilities, workplaces, public places and public transport in all Member States declared 100% tobacco-free. Update MoH on-line database obtained from utilizing TQS in all Member States.
(2)
(3)
(4)
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Regional Strategy for Utilization of Tobacco Questions for Surveys (TQS)
5. 5.1
Strategies Support to formulation of national tobacco control policy and plan of action and enforcement of national legislation The Regional Office will provide technical assistance to Member States for the development and strengthening of their national tobacco control policies and plans of action. All countries should have a clearly stated, comprehensive, accountable and sustainable National Tobacco Control Policy and Plan of Action. Existing plans and policies should be reviewed and amended, based on data obtained from utilizing TQS. TQS will be incorporated in the regional and national plans of action for tobacco control including the following: (1) Advocacy campaigns for policy-makers and responsible personnel in the relevant government ministries and agencies including ministries of health/finance/education/broadcasting/ agriculture/revenue on the situation of tobacco use, exposure to second-hand smoke and advertisement, etc, among the people and the aims and objectives of utilizing data using TQS in the country. Coordination within national statistical offices, national/centres of excellence and other agencies/related ministries for planning utilizing TQS, including problem identification, and development of the questionnaire according to the country need. Coordination with related ministries and authorities for conducting different surveys. Coordination with personnel in related ministries for the preparation of the report. Dissemination of adult data obtained by using TQS through press releases, dissemination workshops, advocacy workshops, publications, formal distribution to departments etc. and through the TFI web site. National policy for utilization of adult data obtained by using TQS for national tobacco control programmes.
(2)
(3) (4) (5)
(6)
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Regional Strategy for Utilization of Tobacco Questions for Surveys (TQS)
5.2
Increasing knowledge on the hazards of tobacco among schoolchildren Adult data obtained by using TQS should be used to emphasize the need to increase knowledge on the hazards of tobacco among the population at large. The Regional Office should provide technical assistance to Member States by providing: (1) (2) (3) Guidelines for development of awareness materials on hazards of tobacco use. Technical assistance to conduct advocacy/training workshops for media personnel on the hazards of tobacco. Technical assistance for counter-marketing activities as a proactive measure against the lure of the tobacco industry with active involvement of people at large.
5.3
Protection from second-hand smoke Global Adult Tobacco survey data from Bangladesh, India, Indonesia and Thailand showed that a high percentage of people were exposed to second-hand smoke at home, workplaces and in public places. WHO could help countries to use this information for the development of plans which should include: (1) Promoting public awareness about the dangers of second-hand smoke (100%) to encourage people to voluntarily make their homes smoke-free. Introducing or strengthening legislation to make all public places smoke-free, including public transport and workplaces (100%). Ban both indoor and outdoor smoking in the premises of all educational institutions (100% ban); libraries, nurseries, day-care centres etc. Ban smoking in the premises of all health institutions (100%).
(2) (3)
(4)
5.4
Ban on advertisement of tobacco products GATS data from Bangladesh, India, Indonesia and Thailand showed that a high percentage of adult population were exposed to tobacco 7
Regional Strategy for Utilization of Tobacco Questions for Surveys (TQS)
advertisements; a considerable percentage had been exposed at point-ofsale and many had seen tobacco promotion and sponsorships through various forms of sports and social entertainment. The WHO Regional Office could help countries to develop strategic plans for prohibition of tobacco advertisement, promotion and sponsorship that should include: (1) Strengthening bans on all forms of direct and indirect advertising of tobacco products, in all media (including electronic, print and, folk, the Internet etc). Strengthening bans on promotion, brand stretching and sponsorship of sports and social events including international events, activities and/or participation therein. Ban on cross-border advertising, promotion and sponsorship originating from its territory, subject to the legal environment and the technical means available to the Member State. Member States should cooperate in the development of technologies and other means necessary to facilitate the cessation of cross-border advertising. Discontinuation of direct or indirect incentives that encourage the purchase of tobacco products.
(2)
(3)
(4)
5.5
Limiting access to tobacco products Adult data obtained by utilizing TQS could be used to advocate with decision-makers and to inform the public on the easy availability of cigarettes and other tobacco products by minors (below 18 years). This should highlight the urgent need to limit access to tobacco products by minors. The Regional Office will provide technical assistance and guidance to Member States to adopt and implement effective legislative, executive, administrative and other measures to prohibit the sale of tobacco products to and by persons under the age set by national law or 18 years. Peopleaccess laws are most effective when administered comprehensively. These measures should include: (1) Requiring that all sellers of tobacco products place clear and prominent indicators inside their points-of-sale regarding prohibition of sales to minors.
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Regional Strategy for Utilization of Tobacco Questions for Surveys (TQS)
(2)
Requiring that all sellers of tobacco products, in case of doubt, request young purchasers (minors) to provide appropriate evidence of having reached the age of majority as determined by domestic law. Ban on the sale of tobacco products in any manner by which they are directly accessible, such as store shelves, vending machines, self-service displays, mail order and electronic sales. Ban on distribution of free samples of tobacco products to the public and especially minors. Ban on the sale of cigarettes and other smoking tobacco products stick-wise, piece-wise, or in small packets which increase the affordability of such products to minors and to the low-income group. Ban on manufacture and sale of snacks, toys, toothpaste, toothpowder or any other objects in the form of tobacco products which appeal to minors; imposing penalties (such as graduated fines) against sellers and distributors, in order to ensure compliance with the regulations. All Member States shall adopt and implement effective measures to prohibit the sale of tobacco products by persons under the age set by national law or 18 years. They should also identify measures that prohibit child labour (minors) in the cultivation, manufacture and sale of tobacco products.
(3)
(4) (5)
(6)
(7)
5.6
Tax policies GATS data from Bangladesh, India, Indonesia and Thailand revealed that cigarettes and other tobacco products are easily affordable by minors. Minors are buying loose sticks mostly. Appropriate tax policies should be formulated to bring about an increase in the real price of tobacco products that is greater than the effect of inflation in order to prevent initiation, as people in this Region are sensitive to price hikes. Measures to bring all tobacco products under the tax and price net should be sought for, in order to avoid substitution of one tobacco product by another. Member States should be encouraged and assisted to earmark a certain portion of the tobacco revenue for implementation of national tobacco control activities.
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Regional Strategy for Utilization of Tobacco Questions for Surveys (TQS)
5.7
Cessation of tobacco use GATS data from Bangladesh, India, and Indonesia and Thailand also showed that a high percentage of people who were current smokers wanted to quit; they also revealed that these people were not receiving adequate support or guidance they needed to quit tobacco by healthcare providers. The Regional Office should provide appropriate guidelines for comprehensive and integrated programmes on cessation, based on scientific evidence and best practices. Effective programmes should be designed and implemented in different settings such as educational and health institutions, healthcare facilities and sporting environments, community settings etc. to provide support for cessation. Health professionals will be trained in regularly advising their patients, its users to quit tobacco use. Quit-line services will be established.
5.8
Surveillance and monitoring of tobacco control activities The online database on tobacco at WHO-SEARO should be updated regularly with adult data obtained by using TQS from countries. SEARO should regularly monitor adult tobacco use, their knowledge and attitude and their exposure to second-hand smoke by utilizing standard questions provided in TQS. SEARO should assist countries to implement TQS in ongoing national surveys periodically and its proper dissemination and use in strengthening tobacco control efforts.
5.9
Identification and mobilization of financial resources Financial resources are crucial to achieve the objectives of the regional strategy for utilization of adult data obtained by using TQS. Each Member State is providing financial support for ongoing surveys in different areas according to their needs. Integration of TQS in those surveys will prove to be a cost effective and consistent measure to monitor tobacco control indicators for adults. Member States promote, as appropriate, the utilization of bilateral, regional, sub-regional and other multilateral channels to provide funding for the implementation and strengthening of comprehensive multisectoral tobacco control programmes. Utilizing TQS as a source is an appropriate opportunity to utilize these channels for consistent and periodic monitoring of tobacco control efforts.
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Regional Strategy for Utilization of Tobacco Questions for Surveys (TQS)
WHO should assist Member States in identifying sources of funding and mobilizing financial resources to implement and sustain national tobacco control programmes; e.g. funds from the long-standing tobacco control partners such as CDC and CDC Foundation, Bloomberg Initiative to Reduce Tobacco Use (Bloomberg Philanthropies), GATES foundation and other international donors such as the European Union and the World Bank. The World Health Organization is well positioned to play a role in providing institutional funding and channeling funding from public and private sources to tobacco control activities. WHO should mobilize extrabudgetary funds to support and further strengthen programmes related to tobacco control. WHO encourages Member States to cooperate with international and regional intergovernmental organizations and with financial and development organizations of which they are members. WHO should strengthen its collaboration with CDC, and the CDC Foundation for sustaining efforts to obtain adult data by using TQS in the interest of comprehensive tobacco control programmes at the country level. Given the high-level commitment to the tobacco control agenda by governments and given the entry into force of WHO FCTC, it is time for countries to allocate national resources for tobacco control activities. Earmarking tax from tobacco revenues should also be used for tobacco control activities/programmes. Government support for tobacco control activities should also be provided as part of the public health infrastructure by directly creating and promoting tobacco control programmes or by offering assistance to health delivery and research institutions.
5.10 Promoting partnerships for tobacco control WHO should provide technical support to promote cooperation among countries to strengthen current capacity building initiatives to include both government and nongovernmental sectors for multisectoral involvement in tobacco control. WHO should strengthen collaboration among the health, finance, trade, law, home and other related departments and international relations sectors at the regional and country levels in order to improve technical capabilities relating to non-health aspects of FCTC, included in WTO regulations. The adult data obtained by using TQS could be used to bring the problem of tobacco into the broad purview of relevant noncommunicable
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Regional Strategy for Utilization of Tobacco Questions for Surveys (TQS)
disease control programmes, health promotion programmes, tuberculosis control programmes and other programmes for poverty reduction and environmental protection. As tobacco production and consumption exacerbate poverty and undermine sustainable development, tobacco control should also be a key component of national development assistance programmes. WHO should identify measures to enhance regional and country-level cooperation and coordination with UN and other international organizations under the UN adhoc task-force mechanism. Partnerships should be enhanced with regional and national NGOs; WHO Collaborating centres; the US Centers for Disease Control and Prevention (CDC), the CDC Foundation and with research and academic institutions to build capacity and to channel resources and expertise for tobacco control at the country level.
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This Regional Strategy for Utilization of Tobacco Questions for Surveys (TQS) provides a strategic direction to use a standard set of questions on tobacco use among adults and other key tobacco control measures in Member States of the WHO South-East Asia Region. Implementation of TQS will result in generating consistent and comparable tobacco information across Member countries, and will support improvement of the existing tobacco control polices and programmes in the Region.
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SEA-Tobacco-46