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Sorensen G.,Dana-Farber Cancer Institute | Pednekar M.S.,Healis Sekhsaria Institute of Public Health | Stoddard A.M.,New England Research Institutes, Inc. | Nagler E.,Dana-Farber Cancer Institute | And 4 more authors.
American Journal of Public Health | Year: 2013

Objectives. We assessed a school-based intervention designed to promote tobacco control among teachers in the Indian state of Bihar. Methods. We used a cluster-randomized design to test the intervention, which comprised educational efforts, tobacco control policies, and cessation support and was tailored to the local social context. In 2009 to 2011, we randomly selected 72 schools from participating school districts and randomly assigned them in blocks (rural or urban) to intervention or delayed-intervention control conditions. Results. Immediately after the intervention, the 30-day quit rate was 50% in the intervention and 15% in the control group (P = .001). At the 9-month postintervention survey, the adjusted 6-month quit rate was 19% in the intervention and 7% in the control group (P = .06). Among teachers employed for the entire academic year of the intervention, the adjusted 6-month abstinence rates were 20% and 5%, respectively, for the intervention and control groups (P = .04). Conclusions. These findings demonstrate the potent impact of an intervention that took advantage of social resources among teachers, who can serve as role models for tobacco control in their communities. Copyright © 2013 by the American Public Health Association®.


Palipudi K.M.,Centers for Disease Control and Prevention | Gupta P.C.,Healis Sekhsaria Institute for Public Health | Sinha D.N.,World Health Organization | Andes L.J.,Centers for Disease Control and Prevention | And 2 more authors.
PLoS ONE | Year: 2012

Background: Tobacco use has been identified as the single biggest cause of inequality in morbidity. The objective of this study is to examine the role of social determinants on current tobacco use in thirteen low-and-middle income countries. Methodology/Principal Findings: We used nationally representative data from the Global Adult Tobacco Survey (GATS) conducted during 2008-2010 in 13 low-and-middle income countries: Bangladesh, China, Egypt, India, Mexico, Philippines, Poland, Russian Federation, Thailand, Turkey, Ukraine, Uruguay, and Viet Nam. These surveys provided information on 209,027 respondent's aged 15 years and above and the country datasets were analyzed individually for estimating current tobacco use across various socio-demographic factors (gender, age, place of residence, education, wealth index, and knowledge on harmful effects of smoking). Multiple logistic regression analysis was used to predict the impact of these determinants on current tobacco use status. Current tobacco use was defined as current smoking or use of smokeless tobacco, either daily or occasionally. Former smokers were excluded from the analysis. Adjusted odds ratios for current tobacco use after controlling other cofactors, was significantly higher for males across all countries and for urban areas in eight of the 13 countries. For educational level, the trend was significant in Bangladesh, Egypt, India, Philippines and Thailand demonstrating decreasing prevalence of tobacco use with increasing levels of education. For wealth index, the trend of decreasing prevalence of tobacco use with increasing wealth was significant for Bangladesh, India, Philippines, Thailand, Turkey, Ukraine, Uruguay and Viet Nam. The trend of decreasing prevalence with increasing levels of knowledge on harmful effects of smoking was significant in China, India, Philippines, Poland, Russian Federation, Thailand, Ukraine and Viet Nam. Conclusions/Significance: These findings demonstrate a significant but varied role of social determinants on current tobacco use within and across countries.


Giovino G.A.,State University of New York at Buffalo | Mirza S.A.,Centers for Disease Control and Prevention | Samet J.M.,University of Southern California | Gupta P.C.,Healis Sekhsaria Institute for Public Health | And 9 more authors.
The Lancet | Year: 2012

Background Despite the high global burden of diseases caused by tobacco, valid and comparable prevalence data for patterns of adult tobacco use and factors infl uencing use are absent for many low-income and middle-income countries. We assess these patterns through analysis of data from the Global Adult Tobacco Survey (GATS). Methods Between Oct 1, 2008, and March 15, 2010, GATS used nationally representative household surveys with comparable methods to obtain relevant information from individuals aged 15 years or older in 14 low-income and middle-income countries (Bangladesh, Brazil, China, Egypt, India, Mexico, Philippines, Poland, Russia, Thailand, Turkey, Ukraine, Uruguay, and Vietnam). We compared weighted point estimates and 95% CIs of tobacco use between these 14 countries and with data from the 2008 UK General Lifestyle Survey and the 2006-07 US Tobacco Use Supplement to the Current Population Survey. All these surveys had cross-sectional study designs. Findings In countries participating in GATS, 486% (95% CI 476-496) of men and 113% (107-120) of women were tobacco users. 407% of men (ranging from 216% in Brazil to 602% in Russia) and 50% of women (05% in Egypt to 244% in Poland) in GATS countries smoked a tobacco product. Manufactured cigarettes were favoured by most smokers (82%) overall, but smokeless tobacco and bidis were commonly used in India and Bangladesh. For individuals who had ever smoked daily, women aged 55-64 years at the time of the survey began smoking at an older age than did equivalently aged men in most GATS countries. However, those individuals who had ever smoked daily and were aged 25-34-years when surveyed started to do so at much the same age in both sexes. Quit ratios were very low (<20% overall) in China, India, Russia, Egypt, and Bangladesh. Interpretation The fi rst wave of GATS showed high rates of smoking in men, early initiation of smoking in women, and low quit ratios, reinforcing the view that eff orts to prevent initiation and promote cessation of tobacco use are needed to reduce associated morbidity and mortality. Funding Bloomberg Philanthropies' Initiative to Reduce Tobacco Use, Bill and Melinda Gates Foundation, Brazilian and Indian Governments.


Viswanath K.,Human Development and Health | Viswanath K.,Dana-Farber Cancer Institute | Ackerson L.K.,University of Massachusetts Lowell | Sorensen G.,Human Development and Health | And 2 more authors.
PLoS ONE | Year: 2010

Background: Exposure to mass media may impact the use of tobacco, a major source of illness and death in India. The objective is to test the association of self-reported tobacco smoking and chewing with frequency of use of four types of mass media: newspapers, radio, television, and movies. Methodology/Principal FindingsL: We analyzed data from a sex-stratified nationally-representative cross-sectional survey of 123,768 women and 74,068 men in India. All models controlled for wealth, education, caste, occupation, urbanicity, religion, marital status, and age. In fully-adjusted models, monthly cinema attendance is associated with increased smoking among women (relative risk [RR]: 1·55; 95% confidence interval [CI]: 1·04-2·31) and men (RR: 1·17; 95% CI: 1·12-1·23) and increased tobacco chewing among men (RR: 1·15; 95% CI: 1·11-1·20). Daily television and radio use is associated with higher likelihood of tobacco chewing among men and women, while daily newspaper use is related to lower likelihood of tobacco chewing among women. Conclusion/Significance: In India, exposure to visual mass media may contribute to increased tobacco consumption in men and women, while newspaper use may suppress the use of tobacco chewing in women. Future studies should investigate the role that different types of media content and media play in influencing other health behaviors. © 2010 Viswanath et al.


Pednekar M.S.,Healis Sekhsaria Institute for Public Health | Sansone G.,Healis Sekhsaria Institute for Public Health | Sansone G.,University of Waterloo | Gupta P.C.,Healis Sekhsaria Institute for Public Health
Alcohol | Year: 2012

The aim of the present study was to examine the association between alcohol, alcohol and tobacco, and mortality in a large adult population in the city of Mumbai. A total of 35,102 men aged 45 years and older were surveyed about their alcohol drinking as part of a cohort study. These respondents were followed up over time, and all deaths were recorded. Compared with those who never drank alcohol, alcohol drinkers had 1.22 times higher risk of mortality, with the highest risk observed for liver disease (hazard ratio [HR] = 3.19). Among ever drinkers, risk of mortality varied according to types (country/desi), frequency (four or less times a week, HR = 1.39), and quantity of alcohol consumed (>100. mL) per day. In addition, country/desi drinkers (HR = 1.34) had the highest mortality risk compared with all other types of alcohol (HR = 0.97). Alcohol drinkers had increased risk of mortality for tuberculosis (HR = 2.53), cerebrovascular disease (HR = 1.83), and liver disease (HR = 3.19). Synergistic joint effect of tobacco and alcohol on mortality was also observed, with lowest risk in never tobacco user drinkers (HR = 1.02) and highest in mixed tobacco user drinkers (HR = 1.79). The results of this study show a direct association between greater consumption of alcohol and increased risk of mortality from alcohol-specific causes. In addition to individual effect, this study demonstrates the synergistic interaction between alcohol and tobacco use in various forms on mortality. © 2012 Elsevier Inc.


Hebert J.R.,Healis Sekhsaria Institute for Public Health | Hebert J.R.,University of South Carolina | Pednekar M.S.,Healis Sekhsaria Institute for Public Health | Gupta P.C.,Healis Sekhsaria Institute for Public Health | Gupta P.C.,University of South Carolina
International Journal of Epidemiology | Year: 2010

Background: Reduction in pulmonary function, as estimated by forced expiratory volume in 1s (FEV 1), has been found to predict all-cause mortality in developed-country populations. This study was designed to examine the association between FEV 1 and mortality in an urban developing-country population. Methods: Data from the large, well-characterized Mumbai Cohort Study (Maharashtra, India) were used to compute hazard ratios (HRs; deaths/100-ml FEV 1) and 95% confidence intervals (CIs) from Cox proportional hazards regression models in which age, tobacco use, education, height and relative body weight were controlled. Results: A total of 13 261 deaths occurred in this cohort of 148 173 individuals. After controlling for important covariates, there was a 1.7% reduction in risk of overall death in women for each 100-ml increment in FEV 1 (HR=0.983; 95% CI=0.980-0.986) and a 1.5% reduction in men (HR=0.985; 95% CI=0.984-0.986). There was a 1.6% reduction in cancer deaths in women (HR=0.984; 95% CI=0.973-0.996) and a 0.8% reduction in men (HR=0.992; 95% CI=0.987-0.997). The largest reductions in women were observed in tuberculosis deaths (3.7%/100-ml increment in FEV 1), and in men in respiratory system deaths (3.2%). Conclusions: In a densely populated urban Indian population, FEV 1 predicted overall and cancer mortality. Effects were larger in women and were not attenuated by exclusion of smokers or restricting analyses to subjects dying >2 years from recruitment. Because FEV 1 may be affected by air pollution, which is worsening in urban areas of most developing countries, further research is recommended to deepen understanding of these factors in relation to mortality. Published by Oxford University Press on behalf of the International Epidemiological Association © The Author 2010; all rights reserved.


Pednekar M.S.,Healis Sekhsaria Institute for Public Health | Gupta R.,Fortis Escorts Hospital | Gupta P.C.,Healis Sekhsaria Institute for Public Health
BMC Public Health | Year: 2011

Background: Influence of education, a marker of SES, on cardiovascular disease (CVD) mortality has not been evaluated in low-income countries. To determine influence of education on CVD mortality a cohort study was performed in India. Methods. 148,173 individuals aged 35 years were recruited in Mumbai during 1991-1997 and followed to ascertain vital status during 1997-2003. Subjects were divided according to educational status into one of the five groups: illiterate, primary school ( 5 years of formal education), middle school (6-8 years), secondary school (9-10 years) and college (> 10 years). Multivariate analyses using Cox proportional hazard model was performed and hazard ratios (HRs) and 95% confidence intervals (CIs) determined. Results: At average follow-up of 5.5 years (774,129 person-years) 13,261 deaths were observed. CVD was the major cause of death in all the five educational groups. Age adjusted all-cause mortality per 100,000 in illiterate to college going men respectively was 2154, 2149, 1793, 1543 and 1187 and CVD mortality was 471, 654, 618, 518 and 450; and in women all-cause mortality was 1444, 949, 896, 981 and 962 and CVD mortality was 429, 301, 267, 426 and 317 (ptrend< 0.01). Compared with illiterate, age-adjusted HRs for CVD mortality in primary school to college going men were 1.36, 1.27, 1.01 and 0.88 (p trend< 0.05) and in women 0.69, 0.55, 1.04 and 0.74, respectively (ptrend> 0.05). Conclusions: Inverse association of literacy status with all-cause mortality was observed in Indian men and women, while, for CVD mortality it was observed only in men. © 2011 Pednekar et al; licensee BioMed Central Ltd.


Raute L.J.,Healis Sekhsaria Institute for Public Health | Gupta P.C.,Healis Sekhsaria Institute for Public Health | Pednekar M.S.,Healis Sekhsaria Institute for Public Health
Indian Journal of Occupational and Environmental Medicine | Year: 2011

Background: Second-hand smoke contains several toxic chemicals that are known to pollute the air and harm people′s health. In India, smoking in public places has been prohibited since October 2008 as a way to reduce second-hand smoke (SHS) exposure. The purpose of the present study was to assess the implementation of smoke-free policies and its impact on indoor air quality by measuring the PM 2.5 levels in bars and restaurants, restaurants, country liquor bars, hookah restaurants and pubs in Mumbai. Materials and Methods: Air quality measurements at 50 venues were conducted by using a "SIDEPAK AM510 Personal Aerosol Monitor" during April to May 2009. Average concentration of PM 2.5 (g/m 3 ) particles was calculated separately for each venue. Results: Smoking was observed in 36% of the surveyed venues during an hour of data collection. The PM 2.5 levels ranged from 16.97 to 1101.76 g/m 3. The average level of PM 2.5 among non-smoking venues was 97.19 g/m 3 and among smoking venues was 363.04 g/m 3. Conclusion: Considerable scope for improvement in implementation of smoke-free policies exists. The PM 2.5 levels were exceedingly high in venues where smoking was observed.


Prabhakar B.,Healis Sekhsaria Institute for Public Health | Narake S.S.,Healis Sekhsaria Institute for Public Health | Pednekar M.S.,Healis Sekhsaria Institute for Public Health
Indian Journal of Cancer | Year: 2012

Background: Identifying social disparities in patterns of tobacco use with regard to education, occupation, and gender characteristics can provide valuable insights into the tobacco use patterns of the population. Aim: We assessed social disparities in tobacco use, smoking, and smokeless tobacco use by examining occupation-, education-, and gender-specific patterns. Setting: About 69,030 Indian residents 15 years in 29 States and 2 Union Territories (UT). Design: Three-stage sampling in urban areas and two-stage sampling in rural areas for selection of households. Materials and Methods: Data has been derived from GATS 2009-2010, wherein the sample was collected through household interviews. Statistical Analysis: Percentages, proportions, adjusted odds ratios (ORs), and 95% confidence interval (CI) were reported. Results: As a person entered adulthood, the prevalence of ever tobacco use increased by 51.5% among men and 28.8% among women. Prevalence was 2.5 times higher in men (mainly smoking) as compared to women (predominantly smokeless form). ORs for tobacco use were higher among illiterate respondents as compared to the college educated (male OR = 4.23, female OR = 8.15). Unemployed, able to work (male OR = 1.50, female OR = 1.23) showed highest risk, while students (male OR = 0.35, female OR = 0.52) showed the least. The combined effect of occupation and education showed synergistic interaction among females and antagonistic interaction among males. Conclusion: The study clearly underscores the individual and joint effects of education and occupation on tobacco use besides discussing variations based on gender. This can have far-reaching policy implications in addressing disparities in tobacco use.


Gupta P.C.,Healis Sekhsaria Institute for Public Health
Indian journal of public health | Year: 2011

Smokeless tobacco use is on the upswing in some parts of the world, including parts of SEAR. It is therefore important to monitor this problem and understand the possible consequences on public health. Material for this review was obtained from documents and data of the World Health Organization, co-authors, colleagues, and searches on key words in PubMed and on Google. Smokeless tobacco use in SEAR, as betel quid with tobacco, declined with increased marketing of cigarettes from the early twentieth century. Smokeless tobacco use began to increase in the 1970s in South Asia, with the marketing of new products made from areca nut and tobacco and convenient packaging. As a consequence, oral precancerous conditions and cancer incidence in young adults have increased significantly. Thailand's successful policies in reducing betel quid use through school health education from the 1920s and in preventing imports of smokeless tobacco products from 1992 are worth emulating by many SEAR countries. India, the largest manufacturing country of smokeless tobacco in the Region, is considering ways to regulate its production. Best practices require the simultaneous control of smokeless and smoking forms of tobacco. Governments in SEAR would do well to adopt strong measures now to control this problem.

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