We are pleased that the World Health Organization (WHO) is developing a pandemic treaty to improve the global response to future pandemics. In their article, De Luca and Ramirez1 rightly argue that a pandemic treaty should be informed by experiences with WHO's existing treaty, the WHO Framework Convention on Tobacco Control (WHO FCTC), which came into force in 2005. However, the authors have mischaracterized the WHO FCTC and made criticisms that could hinder a productive discussion about a treaty for pandemics. | | The authors identify a limited emphasis on “harm reduction” as a key limitation of the WHO FCTC. However, the treaty itself includes “harm reduction strategies” in its definition of tobacco control.2 As the authors indicate, harm reduction encompasses actions “aimed at reducing the negative effects of health behaviors without necessarily extinguishing the problematic health behaviors completely or permanently.”1,3 The WHO FCTC and its guidelines for implementation—which include requiring smoke-free public places; banning tobacco advertising, promotion, and sponsorship; and reducing the attractiveness of tobacco products by limiting flavoring agents—allow the continuation of product use, while reducing t

INTRODUCTION: This study examined reasons why people planned to reduce or stop tobacco consumption and their relationship with MPOWER scores, adjusting for sociodemographic, cultural, and economic factors. METHODS: Data used were Euromonitor International's Voice of the Consumer: Nicotine Survey 2019-2020, World Bank's country income and WHO's MPOWER policy scores. Analytical sample included 21913 adults of legal smoking age in 21 middle- and high-income countries who used nicotine and tobacco products and planned to reduce or stop their consumption in the next 12 months. Poisson regression models with robust error variance, adjusted for sociodemographic and tobacco use covariables, generated adjusted risk ratios (ARRs) of selecting a certain reason to reduce tobacco consumption dependent on continuous MPOWER scores. RESULTS: Main reasons to reduce or stop tobacco consumption were improving health (85%), saving money (65%), pressure from family (19%), and using another substance instead (4%). Country variation was observed by MPOWER scores. Positive associations were found between some MPOWER scores and reasons to reduce or stop tobacco consumption: enforcing bans on tobacco advertising and using another substance (ARR=1.28; 95% CI: 1.11-1.47); warning about dangers of tobacco and saving money (ARR=1.25; 95% CI: 1.19-1.32); offering help to quit tobacco and using another substance (ARR=1.26; 95% CI: 1.10-1.45) or family pressure (ARR=1.11; 95% CI: 1.04-1.17); anti-tobacco campaigns and using another substance (ARR=1.15; 95% CI: 1.08-1.23); and raising taxes and saving money (ARR=1.11; 95% CI: 1.09-1.13). CONCLUSIONS: MPOWER scores are associated with reported reasons to quit tobacco including to improve health, save money, respond to family pressure or use another substance instead.

Thank you for the opportunity to respond to the Correspondence by Drs. Chiang and Bam1 with regards to recurrent TB as a treatment outcome associated with smoking. We appreciate their interest in our article and their questions concerning the three manuscripts that were not included in our meta-analysis.2 The first, by Balian et al.2 was not identified in our updated search in August of 2017. The two other articles, by Masjedi et al.3 and Leung et al.,4 were excluded from our meta-analysis as they included former smokers in their smoking definitions and models. Our meta-analysis attempted to focus solely on current smokers and we excluded articles that specifically identified their exposure group as including former smokers. However, we agree that former smoking may be an important risk factor to consider in future research regarding smoking and TB treatment outcomes. | | We also concur with the conclusion that recurrent TB is an important treatment outcome that should be considered in the context of smoking behavior. This was not explored in our meta-analysis, but we encourage others to include this in future research and reviews of this topic.

INTRODUCTION: We assessed self-reported receipt of help or advice to stop smoking among current tobacco smoking students enrolled in school. METHODS: Using cross-sectional data collected between 2012-2015 from the Global Youth Tobacco Survey (GYTS), and representing the latest year for which data were collected, we calculated prevalence of receipt of help or advice to stop smoking among current tobacco smoking students aged 13-15 years from 56 countries. The sources of help or advice assessed in the GYTS were: 1) from a program or professional, 2) from a friend, and 3) from a family member. Overall response rates ranged from 60.3% in Nicaragua to 99.2% in Sudan. The analytic sample size ranged from 55 in Gabon to 950 in Bulgaria. RESULTS: In 53 of the 56 assessed countries, more than half of current tobacco smoking students received help or advice to quit from either a program or professional, friend, or family member (range=39.9% San Marino to 96.9% Timor-Leste). From a friend or family member only, the range was 37.2% Bahamas to 69.9% Montenegro, and from a program or professional only, the range was 3.7% Latvia to 34.2% Togo. CONCLUSIONS: Family and friends are the most common sources of help or advice to quit smoking among current tobacco smoking students in the GYTS countries assessed, while programs and professionals were the least common. The use of evidence-based measures is critical to prevent and reduce tobacco use among youth and to ensure they are receiving appropriate help or advice to quit.

INTRODUCTION Turkey conducted three rounds of the Global Adult Tobacco Survey (GATS) in 2008, 2012, and 2016 to monitor tobacco use and key tobacco control indicators. The prevalence estimate of adult tobacco use was 31.2% in 2008 and it declined to 27.1% in 2012. METHODS GATS is a nationally-representative, cross-sectional household survey of tobacco-use and related behaviors among adults aged 15 years. Outcome measures were prevalence of current tobacco smoking and interest in quitting smoking. Multivariable logistic regression analyses assessed changes in the adjusted prevalence and predictors of the outcome variables. RESULTS The unadjusted prevalence of tobacco smoking among adults was 31.6% in 2016; a significant increase in the adjusted prevalence of 4.5% from 2012 to 2016. A significant 19.4% decline was observed in interest in quitting smoking from 2012 to 2016. Tobacco smoking was lower among women (adjusted prevalence ratio, APR=0.38) and rural residents (APR=0.79), and higher among adults aged 2564 years compared to those aged 1524 years (APR=1.63), and those who lived with other adults who smoke tobacco (APR=1.55). Predictors of increased interest in quitting smoking included rural residence (APR=1.13), higher education level (APR=1.211.36), awareness of anti-tobacco warnings and advertisements (APR=1.30), and belief that smoking causes severe health consequences (APR=1.57). CONCLUSIONS This study identified opportunities to reduce tobacco smoking and increase interest in quitting, including increasing awareness of the health consequences of smoking and of evidence-based cessation resources. This study highlights Turkeys commitment to assessing or monitoring tobacco use and key tobacco indicators to inform their policies and programs in a changing tobacco landscape. 2022 Summers A. D. et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License. (http://creativecommons.org/licenses/by/4.0)

BACKGROUND: The tobacco product landscape continues to change. No recent data for electronic cigarette (e-cigarette) use have been reported for multiple countries based on nationally representative surveys. We examined prevalence of e-cigarette use and variations by sociodemographic characteristics in 14 countries using Global Adult Tobacco Survey (GATS) data between Jan 1, 2015, and Dec 31, 2018. METHODS: GATS is a nationally representative household survey of tobacco use among adults aged ≥15 years. The analytic sample size ranged from 4347 in Senegal to 74,037 in India. Prevalence of current e-cigarette use was stratified by sociodemographic subgroups. Age-standardized prevalence was estimated according to world 2000-2025 standard population. Significant differences in adjusted prevalence across sociodemographic subgroup was determined by p value for marginal effect contrast in multivariable logistic regression models. FINDINGS: More than 50% of adults in Russia, Romania, and Ukraine and additionally more than 30% of adults in China, Costa Rica, Uruguay, Mexico, and Philippines were aware of e-cigarettes. Crude prevalence of current e-cigarette use ranged from 0.02% (95% CI 0.01%-0.04%) in India to 3.5% (2.9%-4.2%) in Russia. Prevalence was <1% in nine countries. Approximately 18.3 million adults currently used e-cigarettes across the 14 countries. Men had a significantly higher prevalence of current e-cigarette use than women in eight countries. Additionally, higher adjusted prevalence was observed in some countries among young adults aged 15‒24 years, urban residents, and adults with higher education levels and higher wealth index. INTERPRETATION: The study provides needed baseline data on e-cigarette awareness and use. Continued surveillance is essential to inform interventions and policies to prevent initiation and enhance cessation support. FUNDING: None.

According to the WHO, the Region of the Americas has the second lowest tobacco use prevalence of any WHO region.1 WHO projections based on trends since 2000 indicate that the Region of the Americas, which includes both North and South America, is the only region expected to achieve a 30% relative reduction in tobacco use by 2025.1 However, there are approximately 127 million persons who report smoking tobacco in the Americas Region,2 a majority of whom reside in North America.3 North America consists of 23 countries (see table 1) with a combined population of nearly 600 million people, or approximately 7.5% of the world’s population in 2019.4 Among North American countries, data from 2017 for persons aged 15 years or older show current tobacco smoking prevalence ranged from 6.0% in Panama to 27.8% in Cuba.5 Among students aged 13–15 years old in North American countries with available data through 2017, current tobacco smoking prevalence ranged from 4.4% in Dominican Republic to 18.1% in Mexico.5 Tobacco smoking among adults is higher among males than females across North America. However, the difference in prevalence between sexes in the Region of the Americas is among the lowest of any WHO region5; this pattern is particularly pronounced among youth, where tobacco smoking among girls is similar to or higher among boys in most countries.2 5

PURPOSE AND OBJECTIVES: A process evaluation, the Uttarakhand Tobacco Free Initiative (UTFI), was conducted in 49 public high schools and colleges in the state of Uttarakhand, India, to measure program implementation, provide feedback to school administrators, and identify barriers to tobacco control. INTERVENTION APPROACH: UTFI aims to 1) raise awareness and provide education and tools for teachers and school administrators about the dangers of tobacco use and secondhand smoke, 2) encourage participation in student-led activities to promote tobacco-free initiatives, and 3) enforce tobacco-free school policies in the state of Uttarakhand. EVALUATION METHODS: We used the CDC evaluation framework to document key components and lessons learned from the UTFI. We distributed questionnaires to 71 teachers and principals in December 2016, to assess awareness of school activities and policies related to the initiative. Descriptive statistics were computed for quantitative data, and a thematic content analysis was used for qualitative data. RESULTS: Of the 71 participants, 66 (92.9%) were aware of tobacco use policies in schools, and 63 (88.7%) agreed policies were enforced. Sixty-six participants (93.0%) said that they taught tobacco prevention-related topics, and 41 of 70 respondents (58.6%) reported that a student-led group helped to enforce tobacco-free policies in their schools. Of 69 respondents, almost all (n = 66) reported satisfaction with UTFI implementation. Challenges identified were related to tobacco products being readily accessible near school premises, lack of tobacco prevention materials, and tobacco use by school staff. IMPLICATIONS FOR PUBLIC HEALTH: Successes of UTFI were documented by measuring different components of the process, including implementation of program activities and teacher and principal satisfaction. Results might help enhance key processes for the initiative and highlight some barriers to implementation, such as enforcing tobacco control policy off school premises. Continued efforts are needed to prevent tobacco use among young people.

BACKGROUND: Five data-to-action workshops were conducted during 2016-2019 with participants from 38 countries. The purpose of the workshops is to use data to inform and disseminate tobacco prevention and control strategies. We evaluated the workshops using the Kirkpatrick Model for evaluation of trainings. METHODS: We evaluated the data-to-action workshops in three topic areas: (1) if the workshop was clear, useful, engaging, and relevant to the participant's work, (2) self-reported knowledge and skills for tobacco control topics, and (3) intention to apply the knowledge learned. We used nonparametric tests (one-sided Wilcoxon signed-rank test) and conducted descriptive analysis to assess the difference between pre- and postworkshop scores in each topic area. Free text data from open-ended responses were analyzed in Excel using thematic content analysis. RESULTS: Participants reported the workshop had a clear purpose (93.6%, n = 73), was well organized (94.9%, n = 74), and relevant to their work (96.2%, n = 76). There was a statistically significant increase in median learning scores across all three knowledge and five skills topic areas (p < 0.05); more than 95% of participants intended to apply the knowledge they obtained during the workshop and planned to perform new skills learned in the workshop. CONCLUSIONS: Programs interested in replicating a similar successful model may incorporate a mix of modes of instruction and hands-on experiences, as well as focus on the selection of the right audience, for their workshops. These workshops pose an opportunity for countries to enhance use and dissemination of their tobacco control data.

Introduction: About 80% of the 1.1 billion people who smoke tobacco worldwide reside in low- and middle-income countries. Evidence-based approaches to promote cessation include brief advice from health professionals and referrals through quitlines. This study assesses cessation behaviors and the use of cessation services in the past 12 months among current tobacco smokers in 31 countries who attempted to quit. Methods: Data came from the Global Adult Tobacco Survey, a household-based survey of non-institutionalized adults aged ≥15 years. Surveys were conducted in 31 countries during 2008–2018; sample sizes ranged from 4,250 (Malaysia) to 74,037 (India), and response rates ranged from 64.4% (Ukraine) to 98.5% (Qatar). In 2019, data from the 31 countries were assessed in June 2019, and indicators included self-reported current (daily or less than daily) tobacco smoking, past-year quit attempts, and cessation methods used in the past 12 months. Results: Current tobacco smoking prevalence ranged from 3.7% (Ethiopia) to 38.2% (Greece). Overall, an estimated 176.8 million adults from the 31 countries made a quit attempt in the past 12 months, with country-level prevalence ranging from 16.4% (Greece) to 54.7% (Botswana). Most individuals who made a quit attempt did so without assistance (median=74.4%). Other methods were less prevalent, including quitlines (median=0.2%) and counseling (median=7.2%). Conclusions: In the assessed countries, the majority of those who currently smoked tobacco and made a quit attempt did so without assistance; very few reported using quitlines, partly because of the lack of quitlines in some countries. In resource-limited settings, quitlines can play a greater role in helping people quit smoking as part of a comprehensive approach.

Data from the Global Adult Tobacco Survey from 31 countries between 2008–18 show that more than 176 million smokers attempted to quit in the past 12 months, and most reported little to no assistance when quitting.1 During the COVID-19 pandemic, researchers have highlighted the association between tobacco smoking and adverse COVID-19 disease outcomes, and the need for smokers to quit.2 Evidence from the US Surgeon General's report shows that cigarette smoking can suppress the immune system, increase the risk of respiratory infections, increase the risk of respiratory illnesses such as chronic obstructive pulmonary disease and asthma, and cause heart and lung diseases. Cigarette smoking is associated with severe clinical outcomes for people with other types of coronaviruses, including Middle East respiratory syndrome.3

BACKGROUND: We revisited the association between progress in MPOWER implementation from 2008 to 2016 and smoking prevalence from 2009 to 2017 and offered an in-depth understanding of differential outcomes for various country groups. METHODS: We used data from six rounds of the WHO Reports on the Global Tobacco Epidemic and calculated a composite MPOWER Score for each country in each period. We categorised the countries in four initial conditions based on their tobacco control preparedness measured by MPOWER score in 2008 and smoking burden measured by age-adjusted adult daily smoking prevalence in 2006: (1) High MPOWER - high prevalence (HM-HP). (2) High MPOWER - low prevalence (HM-LP). (3) Low MPOWER - high prevalence (LM-HP). (4) Low MPOWER - low prevalence (LM-LP). We estimated the association of age-adjusted adult daily smoking prevalence with MPOWER Score and cigarette tax rates using two-way fixed-effects panel regression models including both year and country fixed effects. RESULTS: A unit increase of the MPOWER Score was associated with 0.39 and 0.50 percentage points decrease in adult daily smoking prevalence for HM-HP and HM-LP countries, respectively. When tax rate was controlled for separately from MPOWE, an increase in tax rate showed a negative association with daily smoking prevalence for HM-HP and LM-LP countries, while the MPOWE Score showed a negative association for all initial condition country groups except for LM-LP countries. CONCLUSION: A decade after the introduction of the WHO MPOWER package, we observed that the countries with higher initial tobacco control preparedness and higher smoking burden were able to reduce the adult daily smoking prevalence significantly.

Tobacco use and secondhand smoke (SHS) exposure are harmful to development and have significant health risks across the life span, including asthma, respiratory infections, cardiovascular disease, and cancer.1 Most adults begin smoking during adolescence, highlighting the importance of clinical and public health interventions to prevent tobacco use and encourage youth cessation. Data from the US Centers for Disease Control and Prevention (CDC) Global Youth Tobacco Surveys (GYTS) from 61 countries reveal that a substantial number of youth report current cigarette smoking (mean prevalence: 10.7%, range: 1.7%–35%), and .50% of young smokers wish to quit.2 Globally, GYTS data indicate that youth who have never used tobacco products are susceptible to begin using them (Fig 1). In the United States, 5.8% of high schoolers currently smoke cigarettes, 58% of young smokers want to quit, and nearly half are susceptible to using cigarettes or electronic cigarettes (e-cigarettes).3 Thus, global efforts to protect youth against such vulnerabilities are critical to ensure future tobacco-free generations. In this report, we describe a partnership between CDC and the American Academy of Pediatrics (AAP) that highlights how strategic relationships can foster change.

INTRODUCTION: In 2003, the Philippines implemented legislation that prohibited the sale of tobacco products to youth, placed text warning labels on tobacco products, and prohibited tobacco smoking in public places. This study assessed if this legislation was associated with reduced cigarette smoking among youth. METHODS: Data came from the 2000-2015 Philippines Global Youth Tobacco Survey (GYTS), a nationally representative, cross-sectional survey of students aged 13-15 years. GYTS data were used to determine associations between tobacco control legislation and current, past 30-day, current cigarette smoking (CCS). Logistic regression models were adjusted for age, sex, current other tobacco product use (COTPU), and price per cigarette stick (PPCS). RESULTS: In the unadjusted model, the 2003 legislation was not associated with CCS (OR=0.77; 95% CI: 0.54-1.10). After adjusting for covariates, it was negatively associated (AOR=0.65; 95% CI: 0.53-0.80). Being 15 years old (OR=1.31; 95% CI: 1.08-1.58), male (OR=2.54; 95% CI: 2.17-2.98), and COTPU (OR=4.12; 95% CI: 3.47-4.91) were positively associated with CCS in unadjusted models. In adjusted models, being 14 years old (AOR=1.29; 95% CI: 1.08-1.53), 15 years old (AOR=1.55; 95% CI: 1.31-1.84), male (AOR=2.49; 95% CI: 2.13-2.91), and COTPU (AOR=3.96; 95% CI: 3.32-4.73), were associated with CCS. PPCS was not associated with CCS in either the unadjusted (OR=1.32; 95% CI: 0.82-2.11) or adjusted (AOR=1.32; 95% CI: 0.79-2.18) models. CONCLUSIONS: After adjusting for covariates, the 2003 tobacco control legislation was associated with lower current cigarette smoking, but price per cigarette stick was not.

BACKGROUND: Cigarette smoking contributes to tuberculosis (TB) epidemiology. However, limited evidence exists on how smoking impacts TB treatment outcomes such as treatment loss to follow-up and culture conversion.METHODS: This meta-analysis assessed current evidence of the impact of active cigarette smoking on TB treatment outcomes. PubMed, Scopus, Embase, and the Cochrane Library were searched for English-language articles published from database inception through 2017. Articles addressing active pulmonary TB and cigarette smoking were identified and data abstracted. Smokers were defined as those who smoked every day or some days at the time of interview/diagnosis. Non-smokers did not smoke at the time of interview/diagnosis. Unfavorable outcomes included any outcome other than cure or completion of TB treatment. Three different data sets were examined: 8 articles addressing unfavorable treatment outcomes, 9 analyzing only treatment loss to follow-up, and 5 addressing delayed smear or culture conversion. Studies that had <20 subjects or that addressed only populations with comorbidities were excluded.RESULTS: We identified 1030 studies; 21 studies fulfilled the inclusion/exclusion criteria. Smokers had greater odds of unfavorable outcomes (pooled odds ratio [pOR] 1.23, 95%CI 1.14-1.33), delayed smear or culture conversion (pOR 1.55, 95%CI 1.04-2.07), and treatment loss to follow-up (pOR 1.35, 95%CI 1.21-1.50).CONCLUSION: Cigarette smoking is associated with negative treatment results and delayed conversion to negative smear or culture, suggesting smoking is an important factor for consideration in TB elimination efforts.

OBJECTIVES: We sought to examine postpartum contraceptive use among women who reported physical intimate partner violence (IPV) during or within 12 months before pregnancy compared with women who did not report physical IPV and to identify factors associated with nonuse of contraception among women who reported physical IPV. METHODS: Data were obtained from women with a recent live birth from 2012 to 2015 who participated in the Pregnancy Risk Assessment and Monitoring System. We described characteristics of women and postpartum contraceptive use by method effectiveness (most effective [female sterilization, male sterilization, intrauterine device, implant], moderately effective [injectable, pill, patch, ring], less effective [condoms, natural family planning, withdrawal, other]) or no method, stratified by reported physical IPV. Multivariable logistic regression was used to examine characteristics associated with nonuse of contraception among women who reported physical IPV. RESULTS: The proportion of women using most or moderately effective contraception was similar for women reporting and not reporting physical IPV. Less effective contraceptive use was lower among women who reported physical IPV (13.9%) than who did not report physical IPV (25.1%) (p < .001). Nonuse was higher among women who reported physical IPV (33%) than who did not report physical IPV (21%) (p < .001). Having no health insurance at the time of survey and experiencing traumatic stress within 12 months before delivery were associated with nonuse of contraception among women who reported physical IPV. CONCLUSIONS: The higher proportion of contraception nonuse among women who reported physical IPV indicates a potential unmet need for contraception among this vulnerable population. Recommended screening for IPV and counseling about the full range of contraceptive methods should begin during pregnancy and continue through the postpartum period.

Each year, tobacco use is responsible for approximately 8 million deaths worldwide, including 7 million deaths among persons who use tobacco and 1.2 million deaths among nonsmokers exposed to secondhand smoke (SHS) (1). Approximately 80% of the 1.1 billion persons who smoke tobacco worldwide reside in low- and middle-income countries (2,3). The World Health Organization's (WHO's) Framework Convention on Tobacco Control (FCTC) provides the foundation for countries to implement and manage tobacco control through the MPOWER policy package,* which includes monitoring tobacco use, protecting persons from SHS, warning them about the danger of tobacco, and enforcing bans on tobacco advertising, promotion, or sponsorship (tobacco advertising) (4). CDC analyzed data from 11 countries that completed two or more rounds of the Global Adult Tobacco Survey (GATS) during 2008-2017. Tobacco use and tobacco-related behaviors that were assessed included current tobacco use, SHS exposure, thinking about quitting because of warning labels, and exposure to tobacco advertising. Across the assessed countries, the estimated percentage change in tobacco use from the first round to the most recent round ranged from -21.5% in Russia to 1.1% in Turkey. Estimated percentage change in SHS exposure ranged from -71.5% in Turkey to 72.9% in Thailand. Estimated percentage change in thinking about quitting because of warning labels ranged from 77.4% in India to -33.0% in Turkey. Estimated percentage change in exposure to tobacco advertising ranged from -66.1% in Russia to 44.2% in Thailand. Continued implementation and enforcement of proven tobacco control interventions and strategies at the country level, as outlined in MPOWER, can help reduce tobacco-related morbidity and mortality worldwide (3,5,6).

Introduction: Hardened smokers are those who do not want to quit, or find it very difficult to quit. This study assessed the prevalence and predictors of hardened smokers in 19 low- and middle-income countries (LMICs). | | Methods: We used nationally representative data from 19 LMICs that conducted the Global Adult Tobacco Survey during 2009-2013. Our analysis is restricted to adults aged ≥25 years. Hardened smokers were defined as daily smokers who smoked for 5 or more years, and who reported the following: no quit attempt in the past year that lasted 24 or more hours; no interest in quitting, or not planning to quit in the next year; and currently smoked within 30 minutes after waking. For each country, the prevalence of hardened smokers was analyzed by sex, age, residence (urban or rural), educational attainment, wealth index, and knowledge of the danger of smoking. Multivariable logistic regression was used to assess predictors of hardened smoking. | | Results: Prevalence of hardened smokers among adults (aged ≥25 years) ranged from 1.1% (Panama) to 14.3% (Russia). Among current smokers (aged ≥25 years), the proportion of hardened smokers ranged from 7.5% (Mexico) to 38.4% (Romania). Adjusted odds of hardened smokers were significantly higher for males (9 of 19 countries), smokers aged 65 years or older (12 of 19 countries), adults with lower educational attainment (9 of 19 countries), and no knowledge of the danger of smoking (8 of 19 countries). | | Conclusions: The spectrum of smokers in the LMICs includes hardened smokers and prevalence varies across population groups. Full implementation of proven tobacco control strategies could reduce hardened smoking in LMICs.

Use of some medications during pregnancy can be harmful to the developing fetus, and discussion of the risks and benefits with prenatal care providers can provide guidance to pregnant women. We used Pregnancy Risk Assessment Monitoring System data collected for 2015 births aggregated from 34 US states (n=40,480 women) to estimate the prevalence of self-reported receipt of prenatal care provider counseling about medications safe to take during pregnancy. We examined associations between counseling and maternal characteristics using adjusted prevalence ratios (aPR). The prevalence of counseling on medications safe to take during pregnancy was 89.2% (95% confidence interval [CI]: 88.7-89.7). Women who were nulliparous versus multiparous (aPR 1.03; 95% CI: 1.02-1.04), who used prescription medications before pregnancy versus those who did not, (aPR 1.03; 95% CI: 1.02-1.05), and who reported having asthma before pregnancy versus those who did not, (aPR 1.05; 95% CI: 1.01-1.08) were more likely to report receipt of counseling. There was no difference in counseling for women with pre-pregnancy diabetes, hypertension, and/or depression compared to those without. Women who entered prenatal care after the first trimester were less likely to report receipt of counseling (aPR 0.93; 95% CI: 0.91-0.96). Overall, self-reported receipt of counseling was high, with some differences by maternal characteristics. Although effect estimates were small, it is important to ensure that information is available to prenatal care providers about medication safety during pregnancy, and that messages are communicated to women who are or might become pregnant.

Each year, tobacco use causes approximately 7 million deaths worldwide, including approximately 6 million among tobacco users and an estimated 890,000 among nonsmokers exposed to secondhand smoke (1). Tobacco use is a leading preventable cause of disease globally and has been determined to cause adverse health outcomes such as coronary heart disease, stroke, and multiple types of cancer, including lung cancer (2-4). Approximately 80% of the world's 1.1 billion tobacco smokers reside in low- and middle-income countries (4). Some persons do not fully understand the health risks associated with tobacco smoking (5-9), and studies have indicated that increasing knowledge about the adverse health effects of smoking can contribute to decreases in smoking, increases in cessation attempts, and increases in successful cessation (3,7,10). CDC analyzed 2008-2016 Global Adult Tobacco Survey (GATS) data from 28 countries to assess tobacco smoking prevalence, quit attempts, and knowledge about tobacco smoking risks among persons aged >/=15 years. Across countries, the median prevalence of tobacco smoking was 22.5%, and a median of 42.5% of tobacco smokers had made a quit attempt in the preceding 12 months. The median prevalences of knowing that tobacco smoking causes stroke, heart attack, and lung cancer were 73.6%, 83.6%, and 95.2%, respectively. Implementation of proven tobacco control interventions, including strategies that increase knowledge about the health risks posed by tobacco use, might help to reduce tobacco use and tobacco-related disease, including heart disease, stroke, and lung cancer (3-5).

Introduction Racial/ethnic inequities in low birth weight (LBW) and preterm birth (PTB) persist in the United States. Research has identified numerous risk factors for adverse birth outcomes; however, they do not fully explain the occurrence of, or inequalities in PTB/LBW. Stress has been proposed as one explanation for differences in LBW and PTB by race/ethnicity. Methods Using the Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2012 to 2013 for 21 states and one city (n = 15,915) we used Poisson regression to estimate the association between acute, financial and relationship stressors and LBW and PTB, and to examine the contribution of these stressors individually and simultaneously to racial/ethnic differences in LBW and PTB. Results Adjusting for age and race/ethnicity, acute (p < 0.001), financial (p < 0.001) and relationship (p < 0.05) stressors were associated with increased risk of LBW, but only acute (p < 0.05) and financial (p < 0.01) stress increased risk of PTB. Across all models, non-Hispanic blacks had higher risk of LBW and PTB relative to non-Hispanic whites (IRR 1.87, 95% CI 1.55, 2.27 and IRR 1.46, 95% CI 1.18, 1.79). Accounting for the effects of stressors attenuated the risk of LBW and PTB by 17 and 22% respectively, but did not fully explain the increased likelihood of LBW and PTB among non-Hispanic blacks. Discussion Results of this study demonstrate that stress may increase the risk of LBW and PTB. While stressors may contribute to racial/ethnic differences in LBW and PTB, they do not fully explain them. Mitigating stress during pregnancy may help promote healthier birth outcomes and reduce racial/ethnic inequities in LBW and PTB.

OBJECTIVE: The World Health Organization recommends that smokers be offered help to quit. A better understanding of smokers' interest in and commitment to quitting could guide tobacco control efforts. We assessed temporal differences in stages of change toward quitting among smokers in Thailand and Turkey. METHODS: Two waves (independent samples) of data from the Global Adult Tobacco Survey, a national household survey of adults aged 15 years or older, were assessed for Thailand (2009 and 2011) and Turkey (2008 and 2012). Current smokers were categorized into 3 stages of change based on their cessation status: precontemplation, contemplation, and preparation. Relative change in the proportion of smokers in each stage between waves 1 and 2 was computed for each country. RESULTS: Between waves, overall current tobacco smoking did not change in Thailand (23.7% to 24.0%) but declined in Turkey (31.2% to 27.1%; P < .001). Between 2009 and 2011, precontemplation increased among smokers in Thailand (76.1% to 85.4%; P < .001), whereas contemplation (17.6% to 12.0%; P < .001) and preparation (6.3% to 2.6%; P < .001) declined. Between 2008 and 2012, there were declines in precontemplation among smokers in Turkey (72.2% to 64.6%; P < .001), whereas there were increases in contemplation (21.2% to 26.9%; P = .008) and no significant change in preparation (6.5% to 8.5%; P = .097). CONCLUSION: Nearly two-thirds of smokers in Turkey and more than two-thirds in Thailand were in the precontemplation stage during the last survey wave assessed. The proportion of smokers in the preparation stage increased in Turkey but declined in Thailand. Identifying stages of cessation helps guide population-based targeted interventions to support smokers at varying stages of change toward quitting.

Tobacco use is the world's leading cause of preventable morbidity and mortality, resulting in nearly 6 million deaths each year (1). Smoked tobacco products, such as cigarettes and cigars, are the most common form of tobacco consumed worldwide (2), and most tobacco smokers begin smoking during adolescence (3). The health benefits of quitting are greater for persons who stop smoking at earlier ages; however, quitting smoking at any age has health benefits (4). CDC used the Global Youth Tobacco Survey (GYTS) data from 61 countries across the six World Health Organization (WHO) regions from 2012 to 2015 to examine the prevalence of current tobacco smoking and desire to quit smoking among students aged 13-15 years. Across all 61 countries, the median current tobacco smoking prevalence among students aged 13-15 years was 10.7% (range = 1.7%, Sri Lanka to 35.0%, Timor-Leste). By sex, the median current tobacco smoking prevalence was 14.6% among males (range = 2.9%, Tajikistan to 61.4%, Timor-Leste) and 7.5% among females (range = 1.6%, Tajikistan to 29.0%, Bulgaria). In the majority of countries assessed, the proportion of current tobacco smokers who desired to quit smoking exceeded 50%. These findings could be used by country level tobacco control programs to inform strategies to prevent and reduce youth tobacco use.

Nearly six million people worldwide die from tobacco-attributable causes every year, making tobacco the leading cause of preventable disease and death.1 If current trends continue, tobacco use is expected to result in one billion deaths by the end of the century, most of these in low- and middle-income countries.2 Cigarette smoking is the most common form of tobacco use in most countries, and the majority of adult smokers try their first cigarette before the age of 18.3,4 | To reduce the public health threat of tobacco use, the World Health Organization (WHO) has promoted the ratification of the WHO Framework Convention on Tobacco Control (FCTC) and developed demand reduction tools to help countries curb tobacco use (http://www.who.int/fctc/reporting/en/). Specifically, the “MPOWER” package advocates the following evidence-based strategies: Monitor tobacco use and prevention policies; Protect people from tobacco smoke; Offer help to quit tobacco use; Warn about the dangers of tobacco; Enforce bans on tobacco advertising, promotion, and sponsorship; and Raise taxes on tobacco. | The “Monitor” strategy can be used to guide tobacco prevention and control policies. One such policy is limiting access to cigarettes, which is an important way to curb the tobacco epidemic because it prevents smoking initiation among youth.3–5 In 2005, the year the FCTC took effect, 28 of 35 countries in the Americas had not implemented any of the MPOWER strategies.6 By the end of 2015, 6 of 35 countries had implemented at least four of the MPOWER strategies, and 15 of 35 countries had implemented one to three strategies.6 Uruguay, which has a strong track record of tobacco control and has implemented most of the MPOWER strategies, has seen rapid declines in cigarette smoking.7

BACKGROUND: The tobacco epidemic in Bangladesh is pervasive. Expenditures on tobacco may reduce money available for food in a country with a high malnutrition rate. OBJECTIVES: The aims of the study are to quantify the opportunity costs of tobacco expenditure in terms of nutrition (ie, food energy) forgone and the potential improvements in the household level food-energy status if the money spent on tobacco were diverted for food consumption. METHOD: We analyzed data from the 2010 Bangladesh Household Income and Expenditure Survey, a nationally representative survey conducted among 12,240 households. We present 2 analytical scenarios: (1) the lower-bound gain scenario entailing money spent on tobacco partially diverted to acquiring food according to households' food consumption share in total expenditures; and (2) the upper-bound gain scenario entailing money spent on tobacco diverted to acquiring food only. Age- and gender-based energy norms were used to identify food-energy deficient households. Data were analyzed by mutually exclusive smoking-only, smokeless-only, and dual-tobacco user households. FINDINGS: On average, a smoking-only household could gain 269-497 kilocalories (kcal) daily under the lower-bound and upper-bound scenarios, respectively. The potential energy gains for smokeless-only and dual-tobacco user households ranged from 148-268 kcal and 508-924 kcal, respectively. Under these lower- and upper-bound estimates, the percentage of smoking-only user households that are malnourished declined significantly from the baseline rate of 38% to 33% and 29%, respectively. For the smokeless-only and dual-tobacco user households, there were 2-3 and 6-9 percentage point drops in the malnutrition prevalence rates. The tobacco expenditure shift could translate to an additional 4.6-7.7 million food-energy malnourished persons meeting their caloric requirements. CONCLUSIONS: The findings suggest that tobacco use reduction could facilitate concomitant improvements in population-level nutrition status and may inform the development and refinement of tobacco prevention and control efforts in Bangladesh.

Tobacco use is a leading preventable cause of morbidity and mortality, with nearly 6 million deaths caused by tobacco use worldwide every year. Cigarette smoking is the most common form of tobacco use in most countries, and the majority of adult smokers initiate smoking before age 18 years. Limiting access to cigarettes among youths is an effective strategy to curb the tobacco epidemic by preventing smoking initiation and reducing the number of new smokers. CDC used the Global Youth Tobacco Survey (GYTS) data from 45 countries to examine the prevalence of current cigarette smoking, purchase of cigarettes from retail outlets, and type of cigarette purchases made among school students aged 13-15 years. The results are presented by the six World Health Organization (WHO) regions: African Region (AFR); Eastern Mediterranean Region (EMR); European Region (EUR); Region of the Americas (AMR); South-East Asian Region (SEAR); and Western Pacific Region (WPR). Across all 45 countries, the median overall current cigarette smoking prevalence among students aged 13-15 years was 6.8% (range = 1.7% [Kazakhstan]-28.9% [Timor-Leste]); the median prevalence among boys was 9.7% (2.0% [Kazakhstan]-53.5% [Timor-Leste]), and among girls was 3.5% (0.0% [Bangladesh]-26.3% [Italy]). The proportion of current cigarette smokers aged 13-15 years who reported purchasing cigarettes from a retail outlet such as a store, street vendor, or kiosk during the past 30 days ranged from 14.9% [Latvia] to 95.1% [Montenegro], and in approximately half the countries, exceeded 50%. In the majority of countries assessed in AFR and SEAR, approximately 40% of cigarette smokers aged 13-15 years reported purchasing individual cigarettes. Approximately half of smokers in all but one country assessed in EUR reported purchasing cigarettes in packs. These findings could be used by countries to inform tobacco control strategies in the retail environment to reduce and prevent marketing and sales of tobacco products to youths.

Tobacco use is a leading cause of preventable morbidity and mortality worldwide, with nearly 6 million tobacco-attributable deaths every year (World Health Organization, 2012). If current trends continue, tobacco use is expected to result in an estimated 1 billion deaths by the end of the century, with most from low- and middle-income countries (Mathers and Loncar, 2006). | Cigarette smoking is the most common form of tobacco use in most countries, and the majority of adult smokers first try cigarettes before age 18 (CDC Foundation, 2015; Anon., 2012). Limiting access to cigarettes among youth is an effective strategy to curb the tobacco epidemic by preventing smoking initiation and reducing the number of new smokers (CDC Foundation, 2015; Anon., 2012; DiFranza, 2012). To reduce the threat posed by tobacco to public health, the World Health Organization (WHO) has promoted the ratification of the WHO Framework Convention for Tobacco Control (FCTC) and has developed demand reduction tools (http://www.who.int/fctc/reporting/en/). The “MPOWER” demand reduction package includes the following strategies to assist countries in addressing the tobacco epidemic: Monitor tobacco use; Protect people from second hand smoke; Offer help to quit tobacco use; Warn about the dangers of tobacco; Enforce bans on tobacco advertising and promotion; Raise taxes on tobacco products.

Pregnant women and infants are at increased risk for influenza-related complications and hospitalization. Influenza vaccination can reduce the risk for influenza-related illness among pregnant women and their infants. Since 2004, the Advisory Committee on Immunization Practices (ACIP) and the American College of Obstetricians and Gynecologists (ACOG) have recommended influenza vaccination for all women who are or will be pregnant during the influenza season, regardless of trimester of pregnancy. To assess influenza vaccination coverage among pregnant women during the 2014-15 influenza season, CDC analyzed data from an Internet panel survey conducted during March 31-April 6, 2015. Among 1,702 survey respondents who were pregnant at any time during October 2014-January 2015, 50.3% reported receiving influenza vaccination before or during pregnancy, similar to the reported coverage in the preceding season. Overall, 64.9% of respondents reported receiving a provider offer of influenza vaccination, 14.8% received a recommendation but no offer, and 20.3% received no recommendation. Vaccination coverage among these groups of women was 67.9%, 33.5%, and 8.5%, respectively. Reminder systems and standing orders that allow health care personnel other than the attending provider to assess vaccination status and administer vaccination, can help to ensure that influenza vaccination is recommended and offered to a pregnant woman at each provider visit to increase pregnant women's vaccination coverage.

PROBLEM/CONDITION: In 2009, before passage of the 2010 Patient Protection and Affordable Care Act (ACA), approximately 20% of women aged 18-64 years had no health insurance coverage. In addition, many women experienced transitions in coverage around the time of pregnancy. Having no health insurance coverage or experiencing gaps or shifts in coverage can be a barrier to receiving preventive health services and treatment for health problems that could affect pregnancy and newborn health. With the passage of ACA, women who were previously uninsured or had insurance that provided inadequate coverage might have better access to health services and better coverage, including additional preventive services with no cost sharing. Because certain elements of ACA (e.g., no lifetime dollar limits, dependent coverage to age 26, and provision of preventive services without cost sharing) were implemented as early as September 2010, data from 2009 can be used as a baseline to measure the incremental impact of ACA on the continuity of health care coverage for women around the time of pregnancy. REPORTING PERIOD COVERED: 2009. DESCRIPTION OF SYSTEM: The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing state- and population-based surveillance system designed to monitor selected maternal behaviors and experiences that occur before, during, and shortly after pregnancy among women who deliver live-born infants in selected U.S. states and New York City, New York. PRAMS uses mixed-mode data collection, in which up to three self-administered surveys are mailed to a sample of mothers, and those who do not respond are contacted for telephone interviews. Self-reported survey data are linked to birth certificate data and weighted for sample design, nonresponse, and noncoverage. Annual PRAMS data sets are created and used to produce statewide estimates of preconception and perinatal health behaviors and experiences in selected states and New York City. This report summarizes data from 29 states that conducted PRAMS in 2009, before the passage of ACA, and achieved an overall weighted response rate of ≥65%. Data on the prevalence of health insurance coverage stability (stable coverage, unstable coverage, and uninsured) across three time periods (the month before pregnancy, during pregnancy, and at the time of delivery) are reported by state and selected maternal characteristics. Women with stable coverage had the same type of health insurance (private or Medicaid) for all three time periods. Women with unstable coverage experienced a change in health insurance coverage between any of the three time periods. This includes movement from having no insurance coverage to gaining coverage, movement from one type of coverage to another, and loss of coverage. Women in the uninsured group had no insurance coverage during any of the three time periods. Estimates for health insurance stability across the three time periods and estimates of coverage during each time period are presented by state. Patterns of movement between the different types of health insurance coverage among women with unstable coverage are described by state and selected maternal characteristics. RESULTS: In 2009, 30.1% of women who had a live birth experienced changes in health insurance coverage in the period between the month before pregnancy and the time of delivery, either because they lacked coverage at some point or because they moved between different types of coverage. Most women had stable coverage across the three time periods, reporting either private coverage (52.8%) or Medicaid coverage (16.1%) throughout. A small percentage of women (1.1%) reported having no health insurance coverage at any point. Overall, Medicaid coverage increased from 16.6% in the month before pregnancy to 43.9% at delivery. Private coverage decreased from 59.9% in the month before pregnancy to 54.6% at delivery. The percentage of women who were uninsured decreased from 23.4% in the month before pregnancy to 1.5% at the time of delivery. Among those who experienced changes in coverage, 74.4% reported having no insurance the month before pregnancy, 23.9% reported having private insurance, and 1.8% reported having Medicaid. Among those who started out uninsured before pregnancy, 70.2% reported Medicaid coverage, and 4.1% reported private coverage at the time of delivery. Among those who started out with private coverage, 21.3% reported Medicaid coverage at delivery, and 1.4% reported being uninsured. As a result of these transitions in health insurance coverage, 92.4% of all women who experienced a change in health insurance around the time of pregnancy reported Medicaid coverage at delivery. No women with unstable coverage who started out without insurance in the month before pregnancy reported being uninsured at the time of delivery. Women who reported unstable coverage were more likely to be young (aged <35 years), be a minority (black, Hispanic, or American Indian/Alaska Native), have a high school education or less, be unmarried, have incomes ≤200% of the federal poverty level (FPL), or have an unintended pregnancy compared with women with stable private coverage. Compared with women with stable Medicaid coverage, women with unstable coverage were more likely to be Hispanic but less likely to be teenagers (aged ≤19 years), be black, have a high school education or less, have incomes ≤200% of the FPL, or have an unintended pregnancy. Women with unstable coverage were more likely than women in either stable coverage group (private or Medicaid) to report entering prenatal care after the first trimester. INTERPRETATION: In 2009, nearly one third of women reported lacking health insurance or transitioning between types of health insurance coverage around the time of pregnancy. The majority of women who changed health insurance status obtained coverage for prenatal care, delivery, or both through Medicaid. Health insurance coverage during pregnancy can help facilitate access to health care and allow for the identification and treatment of health-related issues; however, prenatal coverage might be too late to prevent the consequences of preexisting conditions and preconception exposures that could affect maternal and infant health. Continuous access to health insurance and health care for women of reproductive age could improve maternal and infant health by providing the opportunity to manage or treat conditions that are present before and between pregnancies. PUBLIC HEALTH ACTION: PRAMS data can be used to identify patterns of health insurance coverage among women around the time of pregnancy. Removing barriers to obtaining health insurance for women who lack coverage, particularly before pregnancy, could improve the health of women and their infants. The findings in this report can be used by public health professionals, policy analysts, and others to monitor health insurance coverage for women around the time of pregnancy. In particular, 2009 state-specific data can serve as baseline information to assess and monitor changes in health insurance coverage since the passage of ACA.

An estimated 11.6% of the world cigarette market is illicit, representing more than 650 billion cigarettes a year and $40.5 billion in lost revenue. Illicit tobacco trade refers to any practice related to distributing, selling, or buying tobacco products that is prohibited by law, including tax evasion (sale of tobacco products without payment of applicable taxes), counterfeiting, disguising the origin of products, and smuggling. Illicit trade undermines tobacco prevention and control initiatives by increasing the accessibility and affordability of tobacco products, and reduces government tax revenue streams. The World Health Organization (WHO) Protocol to Eliminate Illicit Trade in Tobacco Products, signed by 54 countries, provides tools for addressing illicit trade through a package of regulatory and governing principles. As of May 2015, only eight countries had ratified or acceded to the illicit trade protocol, with an additional 32 needed for it to become international law (i.e., legally binding). Data from multiple international sources were analyzed to evaluate the 10 most commonly used approaches for addressing illicit trade and to summarize differences in implementation across select countries and the European Union (EU). Although the WHO illicit trade protocol defines shared global standards for addressing illicit trade, countries are guided by their own legal and enforcement frameworks, leading to a diversity of approaches employed across countries. Continued adoption of the methods outlined in the WHO illicit trade protocol might improve the global capacity to reduce illicit trade in tobacco products.