Using Data to Inform and Evaluate Tobacco Control Measures April 22, 2015 Yogyakarta, Indonesia Kalina Duncan, MPH Public Health Advisor Center for Global Health kalina.duncan@nih.gov Twitter: @kalinaduncan @NCIGlobalHealth

Overview Definition of surveillance Tobacco control surveillance systems CDC Global tobacco surveillance systems (GTSS) framework and components Accessing and using GTSS data MPOWER examples Case studies and examples

Surveillance Ongoing, systematic collection, analysis, & interpretation of data essential to planning, implementation, & evaluation of public health practice, integrated with timely dissemination to those responsible for prevention & control. - US CDC Timely, useful evidence to empower public & policy makers to lead & manage effectively. That’s where public health begins.

WHO FCTC Monitoring Protocol 20.2 “…integrate tobacco surveillance programs into national, regional, and global health surveillance programs so that data are comparable and can be analyzed at the regional and international levels, as appropriate.”

Purpose of a Tobacco-Related Surveillance System To provide timely information from populations on: Prevalence of use of tobacco-related products Factors that influence their use Incidence, prevalence, and mortality from tobacco-attributable diseases Impact of tobacco control programs and policies on relevant outcomes

Uses of Tobacco Surveillance Data Understand the natural history and trends of tobacco use and consequences of use Identify emerging issues and research needs (e.g. tobacco harm reduction, SHS exposure) Evaluate tobacco use prevention and control programs, policies, and legislation

Using Existing Tobacco Control Data CDC Global Tobacco Surveillance Data GATS, GYTS National Datasets RISKESDAS/Basic Health Survey/ Indonesia Demographic and Health Survey (IDHS) National Health Information System (HIS) Disease registries Posbindo NCD Risk Factor Screening Program (Ministry of Health) Others

CDC Global Tobacco Surveillance System GLOBAL YOUTH TOBACCO SURVEY GLOBAL ADULT TOBACCO SURVEY TOBACCO QUESTIONS FOR SURVEYS Features: Standardized, systematic & scientific surveys Standard protocol, country adaptations & expert reviews Systematic training & technical exchange Repeats 4-5 years Data Coordinating Center (data bank, quality assurance, data release) Sustainable & efficient Country commitment & partnerships Strengths: Template focused on statistically efficient probability sampling Priority to design comparability Series of manuals & guidelines Training sessions offered to in-country technical/field staff External review of key design components Wide use of handheld technology Commitment to in-country capacity-building Weighted estimates accounting for design complexity

GYTS: Global Youth Tobacco Survey Global Youth Tobacco Survey (GYTS) Global standard for systematically monitoring youth tobacco use & key tobacco control indicators (WHO FCTC & MPOWER).

GYTS Methodology School-based survey of students aged 13-15 Anonymous and confidential self-administered data collection Core questionnaire with optional questions Option for countries to add additional questions Use of answer sheets that can be optically scanned

GYTS in Indonesia 2006, 2009, in the field now Dataset available at: http://nccd.cdc.gov/GTSSData/Default/SelectSurveySite.aspx. (select Indonesia) Highlights: 22.5% of students use tobacco 2/3 of students live in homes where others smoke 8/10 of students who smoke want to quit

GATS: Global Adult Tobacco Survey Global Adult Tobacco Survey (GATS) Household-based survey of adults that aims to collect data on adult tobacco use and key tobacco control measures by using a standard global protocol. Methodology Nationally representative household survey of persons aged 15 years and older Cross sectional estimates by gender and urban/rural Core questionnaire with optional questions Options for countries to add additional questions Face-to-face personal interview survey Electronic data collection using handheld devices

GATS in Indonesia 2011 http://www.who.int/tobacco/surveillance/survey/gats/indonesia_report.pdf

Tobacco Use in Indonesia Source: Campaign for Tobacco Free Kids

Tobacco Questions for Surveys (TQS) 22 Survey questions to collect data on tobacco use prevalence that can be used in national surveys. Currently TQS is integrated into: World Bank Living Standards WHO Stepwise UNICEF National Surveys USAID Demographic and Health Survey Available at: http://www.cdc.gov/tobacco/global/index.htm. Features: Standardized, systematic & scientific surveys Standard protocol, country adaptations & expert reviews Systematic training & technical exchange Repeats 4-5 years Data Coordinating Center (data bank, quality assurance, data release) Sustainable & efficient Country commitment & partnerships Strengths: Template focused on statistically efficient probability sampling Priority to design comparability Series of manuals & guidelines Training sessions offered to in-country technical/field staff External review of key design components Wide use of handheld technology Commitment to in-country capacity-building Weighted estimates accounting for design complexity

Accessing GTSS Data Access GTSSData at www.cdc.gov/tobacco/global Click the GTSSData icon

GTSSData: Home Page Edward

GTSS Data: Indicators by Tobacco Topic or MPOWER Objective View one indicator for all locations View one indicator for all locations View results for one indicator for all countries and regions which have data available. Indicators are organized by tobacco topic or MPOWER objectives. View results for one indicator for all countries and regions which have data available. Indicators are organized by tobacco topic or MPOWER objectives.

Data Sharing & Dissemination Source data files Publications Public use datasets Key Products Fact Sheets Country Reports

Country Fact Sheets and Reports

MPOWER: M - Monitor Monitor tobacco use and prevention policies Obtain nationally representative data on youth and adults Critical to understanding and reversing the epidemic and ensuring success of the other five MPOWER measures

MONITOR: Tobacco Use by Gender Prevalence (%) Male Female Global Adult Tobacco Survey, 2008-2012 22

MPOWER: P Protect People from Tobacco Smoke Exposure to smoke at work (for people who work outside the home) Exposure to smoke in the home Source: Giovino

PROTECT: SHS Exposure at Workplace * In the past 30 days preceding the survey Global Adult Tobacco Survey, 2008-2012

MPOWER: O Offer Help with Quitting Quit attempts during the previous 12 months Receipt of advice to quit from a doctor or other health care provides

OFFER: Advised to Quit by a Health Care Professional * Among those who visited a Health Care Provider (HCP) in the last 12 months Global Adult Tobacco Survey, 2008-2012

MPOWER: W Warn About the Dangers of Tobacco Noticing anti-cigarette information: In newspapers/magazines On television On cigarette packs Both noticing and thinking about quitting

WARN: Thoughts About Quitting Smoking Because of Warning Labels on Cigarette Packages * Among those who noticed health warning label (WL) on cigarette packages in the past 30 days preceding the survey Global Adult Tobacco Survey, 2008-2012

MPOWER: E Enforce Bans on Tobacco Marketing Noticing cigarette advertising in stores Noticing cigarette promotions: Free samples Sale prices Coupons Free gifts or discounts with purchase Clothing or other items Promotions in the mail Source: Giovino

ENFORCE: Percent Who Noticed Cigarette Marketing in Stores * In the past 30 days preceding the survey Global Adult Tobacco Survey, 2008-2012

MPOWER: R Raise Taxes on Tobacco Purchasing patterns Amount paid for cigarettes

RAISE: Cigarette Affordability * Affordability as the relative income price - median price paid per 2000 sticks as % of per capita GDP Global Adult Tobacco Survey, 2008-2012

Using Data to Inform and Evaluate Tobacco Control Policies Examples from the field…

International Tobacco Control Policy Evaluation Project (ITC) The ITC Project has established a research platform to guide strong, evidence-based implementation of FCTC policies to: Evaluate FCTC policies at the level of the individual smoker Identify the determinants of effective tobacco control policies Disseminate research findings to the global tobacco control community, including researchers, policy makers, and advocates. The International Tobacco Control Policy Evaluation Project (the ITC Project) is the first-ever international cohort study of tobacco use. Its overall objective is to measure the psychosocial and behavioral impact of key national level policies of the WHO Framework Convention on Tobacco Control (FCTC). The ITC Project is a collaborative effort with international health organizations and policymakers in more than 20 countries so far, inhabited by more than 50% of the world's population, 60% of the world's smokers, and 70% of the world's tobacco users. In each country, the ITC Project is conducting prospective cohort surveys to assess the impact and identify the determinants of effective tobacco control policies in each of the following areas: Health warning labels and package descriptors Smoke-free legislation Pricing and taxation of tobacco products Communication and education Cessation Tobacco advertising and promotion Source: http://www.itcproject.org/about

International Tobacco Control Policy Evaluation Project (ITC) The ITC measures the psychosocial and behavioral impact of national level policies of the FCTC, studying: Health warning labels and package descriptors Smoke-free legislation Pricing and taxation of tobacco products Communication and education Cessation Tobacco advertising and promotion The International Tobacco Control Policy Evaluation Project (the ITC Project) is the first-ever international cohort study of tobacco use. Its overall objective is to measure the psychosocial and behavioral impact of key national level policies of the WHO Framework Convention on Tobacco Control (FCTC). The ITC Project is a collaborative effort with international health organizations and policymakers in more than 20 countries so far, inhabited by more than 50% of the world's population, 60% of the world's smokers, and 70% of the world's tobacco users. In each country, the ITC Project is conducting prospective cohort surveys to assess the impact and identify the determinants of effective tobacco control policies in each of the following areas: Health warning labels and package descriptors Smoke-free legislation Pricing and taxation of tobacco products Communication and education Cessation Tobacco advertising and promotion Source: http://www.itcproject.org/about

Global Adult Tobacco Survey Data as a Tool to Monitor the WHO Framework Convention on Tobacco Control (WHO FCTC) Implementation: The Brazilian Case The Global Adult Tobacco Survey (GATS) was conducted in Brazil to provide data on tobacco use in order to monitor the WHO FCTC implementation in the country. Data in this report can be used as baseline for evaluation of new tobacco control approaches in Brazil, vis-à-vis WHO FCTC demand reduction measures. Available at: http://www.mdpi.com/1660-4601/9/7/2520.

Using Data to Inform and Evaluate Tobacco Control Policies Examples from Indonesia…

Using Data to Inform and Evaluate Tobacco Control Policies Linking Global Youth Tobacco Survey (GYTS) data to the WHO Framework Convention on Tobacco Control: the case for Indonesia. Aditama TY1, Pradono J, Rahman K, Warren CW, Jones NR, Asma S, Lee J. RESULTS: This report shows that more than 1 in 10 students (12.6%) currently smoked cigarettes, with the prevalence among boys (24.5%) significantly higher than among girls (2.3%). Of the students who currently smoked, more than 7 in 10 (75.9%) reported that they desired to stop smoking now…. CONCLUSIONS: Tobacco control in Indonesia will likely not move forward until the government evaluates and strengthens existing laws, considers passing new strong laws, and develops protocols for enforcing all laws… Available at: http://www.ncbi.nlm.nih.gov/pubmed/18585772

Using Data to Inform Tobacco Control Policies Examples from Indonesia… Susi Ari Kristina, MPH, PhD