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Background. Ongoing quantification of the disease burden attributable to smoking is important to monitor and strengthen tobacco control policies.Objectives. To estimate the attributable burden due to smoking in South Africa for 2000, 2006 and 2012.Methods. We estimated attributable burden due to smoking for selected causes of death in South African (SA) adults aged ≥35 years for 2000, 2006 and 2012. We combined smoking prevalence results from 15 national surveys (1998 - 2017) and smoking impact ratios using national mortality rates. Relative risks between smoking and select causes of death were derived from local and international data. Results. Smoking prevalence declined from 25.0% in 1998 (40.5% in males, 10.9% in females) to 19.4% in 2012 (31.9% in males, 7.9% in females), but plateaued after 2010. In 2012 tobacco smoking caused an estimated 31 078 deaths (23 444 in males and 7 634 in females), accounting for 6.9% of total deaths of all ages (17.3% of deaths in adults aged ≥35 years), a 10.5% decline overall since 2000 (7% in males; 18% in females). Age-standardised mortality rates (and disability-adjusted life years (DALYs)) similarly declined in all population groups but remained high in the coloured population. Chronic obstructive pulmonary disease accounted for most tobacco-attributed deaths (6 373), followed by lung cancer (4 923), ischaemic heart disease (4 216), tuberculosis (2 326) and lower respiratory infections (1 950). The distribution of major causes of smoking-attributable deaths shows a middle- to high-income pattern in whites and Asians, and a middle- to low-income pattern in coloureds and black Africans. The role of infectious lung disease (TB and LRIs) has been underappreciated. These diseases comprised 21.0% of deaths among black Africans compared with only 4.3% among whites. It is concerning that smoking rates have plateaued since 2010. Conclusion. The gains achieved in reducing smoking prevalence in SA have been eroded since 2010. An increase in excise taxes is the most effective measure for reducing smoking prevalence. The advent of serious respiratory pandemics such as COVID-19 has increased the urgency of considering the role that smoking cessation/abstinence can play in the prevention of, and post-hospital recovery from, any condition.

Background: Physician-led smoking cessation services are suboptimal in Nigeria. Objectives: This study evaluated a text messaging intervention designed to increase the knowledge and practices of physicians in Nigeria to help smokers quit. Methods: Using a pre-post study design, all physicians ( N = 946) in 3 tertiary care hospitals located in 3 geopolitical zones in Nigeria were sent 2–3 text messages weekly over a 13-week period to create awareness and improve cessation practices using the “Ask, Advise and Refer” (AAR) model. The primary outcomes were the awareness of AAR and the proportion of physicians who offered each of the components of the brief intervention (AAR) to at least half of eligible patients. Secondary outcomes included the attitudes and self-reported effects of the messages on motivation to offer AAR to patients who smoke. Results: Of the 946 eligible respondents, only 165 responded to both the before and after intervention surveys (17.4% participation rate). Participants were more likely to indicate awareness of the AAR approach after the intervention (60%) than before (21.2%). Overall, physicians’ practice of each component of the AAR changed significantly after the intervention ( P Conclusions: A brief and low-cost text messaging intervention to physicians increased the awareness and practice of AAR in those who participated in the study. However, the relatively low participation rate highlights the importance of new research to improve and expand text messaging as an intervention among physicians to help them foster tobacco treatment among their patients.

Key Points Question Were coronavirus disease 2019 (COVID-19)–related government-mandated closures and restrictions associated with changes in aggregate mobility and the spread of COVID-19 in Nigeria? Findings In this cross-sectional study of data from smartphone users throughout Nigeria, closures and restrictions had significant associations with aggregate mobility trends and may have been associated with averting up 5.8 million severe acute respiratory syndrome coronavirus 2 infections over the study period. Accelerated community spread of COVID-19 was noted in residential areas, transit hubs, and workplaces. Meaning These findings suggest that government-mandated closures and restrictions may have slowed the spread of COVID-19 in Nigeria., This cross-sectional study uses data from smartphone users to examine the association of government-mandated closures and restrictions with aggregate mobility and the association of changes in mobility with confirmed SARS-CoV-2 infections in Nigeria., Importance To prepare for future coronavirus disease 2019 (COVID-19) waves, Nigerian policy makers need insights into community spread of COVID-19 and changes in rates of infection associated with government-mandated closures and restrictions. Objectives To measure the association of closures and restrictions with aggregate mobility and the association of mobility with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and to characterize community spread of COVID-19. Design, Setting, and Participants This cross-sectional study used aggregated anonymized mobility data from smartphone users in Nigeria who opted to provide location history (from a pool of up to 40 million individuals) collected between February 27 and July 21, 2020. The analyzed data included daily counts of confirmed SARS-CoV-2 infections and daily changes in aggregate mobility across 6 categories: retail and recreation, grocery and pharmacy, parks, transit stations, workplaces, and residential. Closures and restrictions were initiated on March 30, 2020, and partially eased on May 4, 2020. Main Outcomes and Measures Interrupted time series were used to measure associations of closures and restrictions with aggregate mobility. Negative binomial regression was used to evaluate associations between confirmed SARS-CoV-2 infections and mobility categories. Averted infections were estimated by subtracting cumulative confirmed infections from estimated infections assuming no closures and restrictions. Results Closures and restrictions had negative associations with mean change in daily aggregate mobility in retail and recreation (–46.87 [95% CI, –55.98 to –37.76] percentage points; P

Current South African tobacco control law allows for 25% designated smoking areas in some indoor public places. This study investigates non-smokers&rsquo, exposure to second-hand smoke (SHS) in workplaces, homes, caf&eacute, s/restaurants, and shebeens (local bars) using data from the 2017 South African Social Attitude Survey. Factors associated with any level of exposure were explored using multiple-variable-adjusted logistic regression analysis. The sample of 3063 participants (16+ years old), comprised 51.7% females and 78.5% Black Africans. The current smoking prevalence from this study was 21.5%. About 47% of non-smokers reported exposure to SHS in at least one location. Females were significantly less likely to be exposed to SHS in all locations except at home compared to males. Adjusted logistic regression analysis showed that females, adults aged 45&ndash, 54 years, 55&ndash, 64 years, and 65+ years were significantly less likely to be exposed to SHS (AOR = 0.63, 0.60, 0.55, and 0.24, respectively) than males and those aged 16&ndash, 24 years. Those who identified as Coloureds were significantly more likely to be exposed to SHS (AOR = 1.69) than Black Africans. This study found that nearly half of non-smokers reported exposure to SHS. A 100% smoke-free policy consistent with the World Health Organisation (WHO) Framework Convention on Tobacco Control would protect more people from exposure to SHS in South Africa.

Summary Background Tobacco use among people living with HIV results in excess morbidity and mortality. However, very little is known about the extent of tobacco use among people living with HIV in low-income and middle-income countries (LMICs). We assessed the prevalence of tobacco use among people living with HIV in LMICs. Methods We used Demographic and Health Survey data collected between 2003 and 2014 from 28 LMICs where both tobacco use and HIV test data were made publicly available. We estimated the country-specific, regional, and overall prevalence of current tobacco use (smoked, smokeless, and any tobacco use) among 6729 HIV-positive men from 27 LMICs (aged 15–59 years) and 11 495 HIV-positive women from 28 LMICs (aged 15–49 years), and compared them with those in 193 763 HIV-negative men and 222 808 HIV-negative women, respectively. We estimated prevalence separately for males and females as a proportion, and the analysis accounted for sampling weights, clustering, and stratification in the sampling design. We computed pooled regional and overall prevalence estimates through meta-analysis with the application of a random-effects model. We computed country, regional, and overall relative prevalence ratios for tobacco smoking, smokeless tobacco use, and any tobacco use separately for males and females to study differences in prevalence rates between HIV-positive and HIV-negative individuals. Findings The overall prevalence among HIV-positive men was 24·4% (95% CI 21·1–27·8) for tobacco smoking, 3·4% (1·8–5·6) for smokeless tobacco use, and 27·1% (22·8–31·7) for any tobacco use. We found a higher prevalence in HIV-positive men of any tobacco use (risk ratio [RR] 1·41 [95% CI 1·26–1·57]) and tobacco smoking (1·46 [1·30–1·65]) than in HIV-negative men (both p

Background Patient medical records are an objective tool for the systematic identification and treatment of tobacco users. The aim of this study was to assess brief intervention tobacco cessation activities documented by physicians in some select tertiary hospitals in Nigeria. Methods We conducted a cross-sectional descriptive study using information obtained from 1588 randomly selected patient records in six teaching hospitals participating in a study to capacitate physicians to deliver brief advice. Trained data collectors collected data using a uniform checklist prior to the training of the physicians in these hospitals. Results Of the audited health records, 33.1% of patients had documentation of physicians' inquiry of their tobacco use mostly during out-patient clinics (37%) and by a resident doctor/medical officer (42.9%). Among identified tobacco users, it was documented that 12.9% were offered some form of tobacco cessation advice; readiness to quit was recorded in 2.6%; assistance with quitting was documented for 1.5% of tobacco users, while only 0.8% showed documentation of patient follow-up. Males and patients admitted to the hospital were 1.86 times and 2.14 times respectively more likely to have records of physicians' inquiry of their tobacco use. Patients who had tobacco-related morbidities and the unemployed were also more likely to have records of inquiry of their tobacco use. Conclusions There was poor documentation of tobacco use by physicians in these hospitals and many opportunities for brief intervention activities were missed. Efforts to educate the physicians on the importance of documenting tobacco use in clinical notes are recommended. Implications This study provides empirical evidence showing that there is poor documentation of tobacco use inquiry and brief intervention among physicians in tertiary hospitals in Nigeria. Records showing implementation of the 5A's were abysmally low and opportunities for brief intervention may have been missed. In line with the World Health Organization recommendations of Article 14 of the Framework Convention on Tobacco Control, efforts to promote brief intervention among physicians in tertiary hospitals in Nigeria should include an emphasis on appropriate documentation of tobacco control interventions in patient clinical notes.

Background The aim of the study was to identify the proportion of female sex workers, men who have sex with men, and people who inject drugs who had accessed HIV prevention services at public health facilities and peer-led facilities, their level of satisfaction with these services, and perceived barriers and challenges to accessing HIV services from public and peer-led HIV prevention service providers. Methods A mixed-method approach was used to collect data from key populations in the four states in Nigeria. Quantitative data collected included level of satisfaction with and barriers to use of public and peer-led facilities. In-depth interviews and focus-group discussions were conducted to explore reasons for satisfaction with and barriers to use of services. Descriptive and bivariate analyses were was conducted for quantitative data. Qualitative data were summaried, emerging themes identified, described and quotes reflecting the themes corresponding to interview questions highlighted. Results Nine hundred sixty-seven persons responded to questions on the use of public health or/and peer-led facilities. Two hundred thirty-eight (49.4%) respondents had received HIV and sexual and reproductive health services through public health facilities, and 236 (48.7%) had received the services through peer-led facilities. Significantly more respondents were satisfied with the quality of services provided by peer-led organisations than with public health facilities with respect to service providers listening to respondent’s problems and concerns (p = 0.007),privacy and confidentiality (p = 0.04) and respect of rights of service recipients (p = 0.04). Significantly more respondents using peer-led organisations than those using public health facilities identified no barriers to service access (p = 0.003). More respondents using public health facilities than peer-led facilities identified cost of services (p = 0.01), confidentiality (p = 0.002), waiting time (p p = 0.001) as barriers to service access. Thee was no difference in the proportion of respondents willing to discontinue their use of either facilities (p = 0.08). Qualitative data revealed that concerns with access of services at the public health facility were due mainly to stigma and the effects of the same-sex prohibition law. Conclusion Key populations were more satisfied receiving HIV prevention services at peer-led organisations than at public health facilities.

Background There is little evidence on the need for differentiated HIV prevention services for men who have sex with men (MSM), female sex workers (FSW) and people who inject drugs (PWID in Nigeria. The aim of the study was to determine and compare the HIV sexual risk profiles of FSW, MSM and PWID resident in Nigeria; and identify factors associated with condom use among the groups. This will help identify if differentiated HIV prevention services are needed for MSM, FSW and PWID in Nigeria. Methods This is a cross-sectional study. Data on sexual practices (anal, vaginal and oral sex), history of alcohol and psychoactive substance use, and high risk sexual behaviors for HIV infection (inconsistent use of condom) was collected from study FSW, MSM and PWID resident in Enugu, Nassarawa, Benue, and Akwa-Ibom States of Nigeria between April and June, 2015. Association between sexual practices, alcohol and psychoactive substance use, and HIV sexual risk behaviors; and differences in sexual risk behaviors of MSM, FSW and PWID were determined using Pearson chi-square for categorical variables, and t-test for continuous variables. Determinants of condom use in the last 30 days were identified using logistic regression analysis. Results The study population consisted of 188 (38.5%) FSW, 145 (29.7%) MSM and 155 (31.8%) PWID. MSM (AOR: 0.17; 95%CI: 0.05–0.67; p = 0.01) and PWID (AOR: 0.07; 95%CI: 0.02–0.21; p

Alcohol and tobacco use may lead to negative treatment outcomes in tuberculosis (TB) patients, and even more so if they are HIV-infected. We developed and tested the feasibility of a complex behavioral intervention (ProLife) delivered by lay health workers (LHWs) to improve treatment outcomes in TB patients who smoke tobacco and/or drink alcohol, at nine clinics in South Africa. The intervention comprised three brief motivational interviewing (MI) sessions augmented with a short message service (SMS) program, targeting as appropriate: tobacco smoking, harmful or hazardous drinking and medication adherence. Patients received SMSs twice a week. We measured recruitment and retention rates and assessed fidelity to the MI technique (MI Treatment Integrity 4.1 tool). Finally, we explored LHWs’ and patients’ experiences through interviews and semi-structured questionnaires, respectively. We screened 137 TB patients and identified 14 smokers, 13 alcohol drinkers, and 18 patients with both behaviors. Participants’ mean age was 39.8 years, and 82.2% were men. The fidelity assessments pointed to the LHWs’ successful application of key MI skills, but failure to reach MI competency thresholds. Nevertheless, most patients rated the MI sessions as helpful, ascribed positive attributes to their counselors, and reported behavioral changes. SMSs were perceived as reinforcing but difficult language and technical delivery problems were identified as problems. The LHWs’ interview responses suggested that they (a) grasped the basic MI spirit but failed to understand specific MI techniques due to insufficient training practice; (b) perceived ProLife as having benefitted the patients (as well as themselves); (c) viewed the SMSs favorably; but (d) considered limited space and privacy at the clinics as key challenges. The ProLife program targeting multiple risk behaviors in TB patients is acceptable but LHW training protocol, and changes in wording and delivery of SMS are necessary to improve the intervention. Trial registration: ISRCTN14213432

Background South Africa is among the seven highest tuberculosis (TB) burden countries. Harmful lifestyle behaviours, such as smoking and alcohol, and poor adherence to medication can affect clinical outcomes. Modification of these behaviours is likely to improve TB treatment outcomes and has proven possible using motivational interviewing (MI) techniques or use of short message service (SMS) text messaging. There have been no studies assessing the effect of combined MI and SMS interventions on multiple lifestyle factors and TB treatment outcomes. Methods This is a prospective, multicentre, two-arm individual randomised controlled trial looking at the effectiveness and cost-effectiveness of a complex behavioural intervention (the ProLife programme) on improving TB and lifestyle-related outcomes in three provinces of South Africa. The ProLife programme consists of an MI counselling strategy, delivered by lay health workers, augmented with subsequent SMS. We aim to recruit 696 adult participants (aged 18 years and over) with drug-sensitive pulmonary TB who are current smokers and/or report harmful or hazardous alcohol use. Patients will be consecutively enrolled at 27 clinics in three different health districts in South Africa. Participants randomised individually to the intervention arm will receive three MI counselling sessions one month apart. Each MI session will be followed by twice-weekly SMS messages targeting treatment adherence, alcohol use and tobacco smoking, as appropriate. We will assess the effect on TB treatment success, using standard World Health Organization (WHO) treatment outcome definitions (primary outcome), as well as on a range of secondary outcomes including smoking cessation, reduction in alcohol use, and TB medication and anti-retroviral therapy adherence. Secondary outcomes will be measured at the three-month and six-month follow-ups. Discussion This trial aligns with the WHO agenda of integrating TB care with the care for chronic diseases of lifestyle, such as provision of smoking cessation treatments, and with the use of digital technologies. If the ProLife programme is found to be effective and cost-effective, the programme could have significant implications for TB treatment globally and could be successfully implemented in a wide range of TB treatment settings. Trial registration ISRCTN Registry, ISRCTN62728852. Registered on 13 April 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3551-9) contains supplementary material, which is available to authorized users.

Background Men who have sex with men (MSM), female sex workers (FSW) have critical needs for effective HIV prevention tools. This study identified perspectives of MSM, FSW and policy makers on the needs for, barriers to, and challenges with pre-exposure HIV prophylaxis (PrEP); and the logistics required to support roll-out of PrEP for MSM and FSW in Nigeria. Methods Qualitative and quantitative data were collected through a cross-sectional study. The quantitative data were collected through an online survey administered to 519 MSM, FSW and transgender respondents. The qualitative data were collected through 22 focus group discussions with 140 MSM and 80 FSW, and a two-day consultative workshop with 65 participants. Two open-ended questions in the online survey were also a source of qualitative data. Results of the quantitative data were reported descriptively; the qualitative data were inductively examined with a content analytic approach to construct descriptive categories. The findings from the quantitative and qualitative responses were triangulated. Results Four hundred and ninety-four (95.2%) online respondents had heard about PrEP through community dialogue (71.3%), and 439 (84.6%) supported its use by MSM and FSW. Fewer than half of the respondents were aware of the clinical care required for PrEP, and misconceptions about PrEP were common. Stated barriers to PrEP uptake were stigma, cost, frequency of HIV counseling and treatment services required, and possible drug-drug interactions. Concerns included possible condom migration, increased risk for sexually transmitted infections and pregnancy for FSW, and poor adherence to medication and hospital schedules. Participants felt that trained peer educators and HIV-test counselors could provide information and refer clients to clinics that provide PrEP. PrEP can be provided through peer-led facilities for MSM and FSW, though its access should be expanded to all persons who are at substantial risk for HIV to prevent negative labeling of PrEP. Public awareness about the use of antiretrovirals for HIV prevention is needed to prevent labeling of PrEP users as being HIV positive. Conclusion Although MSM and FSW are interested in the use of PrEP, numerous individual and structural barriers need to be addressed to facilitate access to it in Nigeria.

Tobacco use and oral sex (OS) are important risk factors for oral and oropharyngeal Human papillomavirus (HPV) infection. Little is known about the prevalence of OS practice in South Africa. This study aimed to determine the prevalence of OS practice and tobacco use in a South African patient population. This cross-sectional study used a structured questionnaire to collect socio-demographic characteristics, tobacco use, betel nut use and OS practice data from consenting adults (>= 18 years; n = 850). Oral sex practices were recorded for patients 18-45 years-old (n = 514). Data analysis included chi-square and multiple logistic regression analyses. Of the study population, 55.2% (n = 468) were female, 88% (n = 748) self-identified as black Africans and 45.1% (n = 383) were unemployed. Furthermore, 19.7% (n = 167), 6.4% (n = 54) and 2.1% (n = 18) were current smokers, snuff users and betel nut users, respectively. Out of the 514 who answered the questionnaire in relation to OS, 22.8% (n = 115) reported to practice it. Oral sex practice in the age group 18-45 years was most common among the self-identified white participants (41.9%); and among tobacco users than among non-tobacco users (30.9% vs. 20.5%; p = 0.022). A multivariable-adjusted regression model showed that white South Africans were more likely to use tobacco than black Africans (OR = 5.25; 95% CI = 2.21-12.47). The practice of OS was more likely among those 18-35 years-old (OR = 1.67; 95% CI = 1.01-2.74), but had no significant association with tobacco use (OR = 1.06; 95% CI = 0.62-1.83). The observed age and ethnic differences in both risk behaviours suggest a need for targeted population intervention in order to reduce the risk for oral HPV infection.

ObjectiveTo examine the use of different cessation aids among current South African smokers who have ever tried to quit smoking.DesignCross-sectional design.SettingSouth Africa has progressively passed several policies over the past few decades to encourage smoking cessation. Data on cessation behaviours are needed to inform policymaking. We investigated utilisation of evidence-based cessation aids and e-cigarettes among current combustible smokers. Current tobacco use, past quit attempts and use of evidence-based cessation aids (counselling, nicotine replacement therapy or prescription medication) were self-reported. Data were weighted and analysed using descriptive and multivariable approaches (pParticipantsOnline participants were recruited from the national consumer database for News24—South Africa’s largest digital publisher. Of the 18 208 participants aged 18 years or older, there were 5657 current smokers of any combustible tobacco product (cigarettes, cigars, pipes or roll-your-own cigarettes), including 4309 who had ever attempted to quit during their lifetime.ResultsCurrent combustible tobacco smoking prevalence was 22.4% (95% CI: 21.2% to 23.5%), and 98.7% of all current smokers of any combustible tobacco were current cigarette smokers. Awareness of cessation aids was as follows among current combustible tobacco smokers: smoking cessation counselling programmes, 50.8% (95% CI: 48.1% to 53.6%); nicotine replacement therapy, 92.1% (95% CI: 90.5% to 93.6%); prescription cessation medication, 68.2% (95% CI: 65.2% to 70.6%). Awareness of cessation aids was lowest among Black Africans, men, and persons with little or no income. Of all current combustible tobacco smokers, 74.6% (95% CI: 72.2% to 76.7%) had ever attempted to quit and 42.8% (95% CI: 40.0% to 45.4%) of these quit attempters had ever used any cessation aid. Among current combustible smokers who attempted to quit in the past, ever e-cigarette users were more likely than never e-cigarette users to have ever used any cessation aid (50.6% vs 35.9%, pConclusionOnly two in five past quit attempters had ever used counselling/pharmacotherapy. Any putative benefits of e-cigarettes on cessation may be partly attributable to pharmacotherapy/counselling given concurrent use patterns among past quit attempters using e-cigarettes. Comprehensive tobacco control and prevention strategies can help reduce aggregate tobacco consumption.

We assessed US adult smokeless tobacco (SLT) users' exposure and response to SLT health warnings, which are currently in text-only format, covering 30% of the two primary surfaces of SLT containers and 20% of advertisements.Data were from the 2012-2013 National Adult Tobacco Survey. Past 30-day exposure to SLT health warnings among past 30-day SLT users (n=1626) was a self-report of seeing warnings on SLT packages: "Very often," "Often," or "Sometimes" (versus "Rarely" or "Never"). We measured the association between SLT health warning exposure and perceptions of SLT harmfulness and addictiveness using logistic regression.Of past 30-day SLT users, 77.5% reported exposure to SLT health warnings, with lower prevalence reported among females and users of novel SLT products (snus/dissolvable tobacco). Furthermore, exposure reduced linearly with reducing education and annual household income (p0.01). Among exposed past 30-day SLT users, 73.9% reported thinking about the health risks of SLT, while 17.1% reported stopping SLT use on ≥1 occasion within the past 30days. Exposure to SLT warnings was associated with perceived SLT harmfulness (AOR=2.16; 95% CI=1.15-4.04), but not with perceived SLT addictiveness.Socioeconomic disparities found in exposure and response to SLT health warnings can be addressed through implementation of large pictorial warnings.

Background. Smoking cessation is a complex process influenced by factors such as smokers’ nicotine dependence levels, socioeconomic status (SES) and other lifestyle behaviours. Little is known about these relationships in South Africa (SA). Objectives. To explore the relationship between nicotine dependence, SES, lifestyle behaviours and lifetime quit attempts among adult smokers in SA. Methods. This study used data from 2 651 participants aged ≥16 years in the 2011 South African Social Attitudes Survey. Information on SES (measured by asset ownership), binge drinking, physical activity, fruit and vegetable intake, intention to quit smoking and lifetime quit attempts was extracted. Nicotine dependence was measured using the Heaviness of Smoking Index (HSI). All data were weighted to account for the complex survey design and to yield nationally representative estimates. Data analysis included binary logistic regression with high nicotine dependence (HND) defined as HSI ≥4 and lifetime quit attempts as separate outcomes. Results. The prevalence of smoking was 20.1% (31.6% for males and 9.5% for females), and was highest in the mixed-ancestry group (37.0%). Overall, 14.5% of smokers had HND, with a higher proportion in the high-SES group. The odds of HND increased with every 10 years of smoking history (odds ratio (OR) 2.05; 95% confidence interval (CI) 1.40 - 3.00) but decreased among participants who reported frequent physical activity (OR 0.4; 95% CI 0.18 - 0.86) and those who planned to quit (OR 0.37; 95% CI 0.19 - 0.75). Quit attempts were more likely among participants who reported frequent fruit and vegetable intake (OR 1.8; 95% CI 1.07 - 2.98) and less likely among those reporting binge drinking (OR 0.31; 95% CI 0.16 - 0.59) or assessed as having HND (OR 0.32; 95% CI 0.17 - 0.58). Conclusions. Most adult smokers in SA have low nicotine dependence. However, the association of HND with high SES in this study suggests that although cessation treatment based on an integrated lifestyle behavioural intervention package may suffice for most smokers, a more intense cessation treatment package is needed for smokers of higher SES.

This study sought to determine the contributions of socio-economic position and health insurance enrollment in explaining racial disparities in preventive dental visits (PDVs) among South Africans. Data on the dentate adult population participating in the last South African Demographic and Health Survey conducted during 2003–2004 (n = 6,312) was used. Main outcome measure: Reporting making routine yearly PDVs as a preventive measure. Education, material wealth index and nutritional status indicated socio-economic position. Multi-level logistic regression analysis was conducted to determine the predictors of PDVs. A variant of Blinder-Oaxaca decomposition analysis was also conducted. Health insurance coverage was most common among Whites (70%) and least common among black Africans (10.1%) in South Africa. Similarly, a yearly PDV was most frequently reported by Whites (27.8%) and least frequently reported among black Africans (3.1%). Lower education and lower material wealth were associated with lower odds of making PDVs. There was significant interaction between location (urban/rural) and education (p = 0.010). The racial and socio-economic differences in PDVs observed in urban areas were not observed in rural areas. In the general dentate population, having health insurance significantly increased the odds of making PDVs (OR = 4.32; 3.04–6.14) and accounted for 40.3% of the White/non-White gap in the probability of making PDVs. Overall, socio-economic position and health insurance enrollments together accounted for 55.9% (95% CI = 44.9–67.8) of the White/non-White gap in PDVs. Interventions directed at improving both socio-economic position and insurance coverage of non-White South Africans are likely to significantly reduce racial disparities in PDVs.

This study examines predictors of smoking cessation in tuberculosis patients with high HIV co-infection rates in a South African primary care setting. Current smokers were randomly allocated to brief motivational interviewing (n = 205) or receipt of a brief message (n = 204). Multi-level logistic regression was performed to identify predictors of sustained 3- and 6-month abstinence and 7-day point prevalence abstinence (PPA) at 1 month, with the facility as a random effect. The intervention was ineffective among smokers with high nicotine-dependence at 1 month, but was effective for all smokers over longer periods. Higher baseline self-efficacy predicted the 1-month 7-day PPA, but not sustained abstinence. HIV-positive participants' odds of sustained abstinence were about three times higher than those of their HIV-negative counterparts. Results support a more intensive motivational intervention and/or coping skills' training to increase self-efficacy and abstinence rates. Tobacco cessation services can be introduced in tuberculosis services where high HIV co-infection rates occur.

Background: We tested the hypothesis that the extent of secondhand smoke (SHS) exposure among nonsmoking adolescents would be associated with their overall exposure to pro-tobacco social influences. Methods: Data were analyzed using descriptive and multivariate methods from the 2011 Zambia Global Youth Tobacco Survey. Results: The odds of SHS exposure increased with increasing exposure to pro-tobacco advertisements. About 39.5% of the gap in SHS exposure between nonsmokers with low versus high smoking susceptibility was attributable to differences in parental or peer smoking. Conclusions: Sustained efforts are needed to denormalize tobacco use in order to reduce youth susceptibility to tobacco use.

School personnel, who are respected members of the community, may exert significant influence on policy adoption. This study assessed the impact of school personnel's permissiveness toward tobacco industry sponsorship activities on their support for complete bans on tobacco advertisements, comprehensive smoke-free laws and increased tobacco prices. Representative data were obtained from the Global School Personnel Survey for 29 African countries (n = 17 929). Adjusted prevalence ratios (aPR) were calculated using multi-variable Poisson regression models to assess the impact of permissiveness toward tobacco sponsorship activities on support for tobacco control policies (p < 0.05). The median of prevalence of support for different tobacco control policies among all countries was as follows: complete ban on tobacco advertisements (84.9%); comprehensive smoke-free laws (92.4%) and tobacco price increases (80.8%). School personnel who believed that the tobacco industry should be allowed to sponsor school events were significantly less likely to support complete bans on tobacco advertisements [aPR = 0.89; 95% confidence interval (CI) 0.84-0.95] and comprehensive smoke-free laws (aPR = 0.95; 95% CI 0.92-0.98). In contrast, support for complete tobacco advertisement bans was more likely among those who believed that the tobacco industry encourages youths to smoke (aPR = 1.27; 95% CI 1.17-1.37), and among those who taught about health sometimes (aPR = 1.06; 95% CI 1.01-1.11) or a lot (aPR = 1.05; 95% CI 1.01-1.10) compared with those who did not teach about health at all. These findings underscore the need to educate school personnel on tobacco industry's strategies to undermine tobacco control policies. This may help to build school personnel support for laws intended to reduce youth susceptibility, experimentation and established use of tobacco products.

OBJECTIVE We assessed the reliability of a measure of the latent construct "smoking sensory experience." We further measured the relationship between "smoking sensory experience" and smokers' rating of the importance of the appearance of cigarettes/cigarette packs in brand choice and smoking dependence. METHODS Analyses involved a national sample of smokers (n = 633) who participated in the 2010 South African Social Attitudes Survey (N = 3,112). Smokers ranked on a scale of 1-5, the importance of the following attributes in choosing their cigarette brand: health concerns, cost, packaging, taste, satisfaction, and flavor/strength. Using structural equation modeling, an a priori model was specified based on the hypothesis that taste, satisfaction, and flavor/strength are measures of a construct of "smoking sensory experience" and that cigarette packaging would be positively related to "smoking sensory experience." Furthermore, "smoking sensory experience" would be positively related to cigarettes smoked per day. RESULTS The latent construct--"smoking sensory experience" was considered reliable (Cronbach's α = 0.75). The structural equation model confirmed that the specified model fitted the data well (goodness of fit index = 0.993; normed fit index = 0.978; root mean square error of approximation = 0.031). Higher "smoking sensory experience" was positively associated with increasing cigarettes smoked per day (β = 0.12). Higher rating of the cigarette package in brand choice positively covaried with both "smoking sensory experience" (β = 0.29), and higher rating of health considerations (β = 0.42). CONCLUSIONS These findings support the regulation of the appearance of cigarettes/cigarette packs to reduce cigarettes' appeal and abuse liability in line with Article 11 of WHO's Framework Convention on Tobacco Control.

Objectives. We compared patient-reported receipt of smoking cessation counseling from US dentists and physicians. Methods. We analyzed the 2010 to 2011 Tobacco Use Supplement of the Current Population Survey to assess receipt of smoking cessation advice and assistance by a current smoker from a dentist or physician in the past 12 months. Results. Current adult smokers were significantly less likely to be advised to quit smoking during a visit to a dentist (31.2%) than to a physician (64.8%). Among physician patients who were advised to quit, 52.7% received at least 1 form of assistance beyond the simple advice to quit; 24.5% of dental patients received such assistance (P Conclusions. Our results indicate a need for intensified efforts to increase dentist involvement in cessation counseling. System-level changes, coupled with regular training, may enhance self-efficacy of dentists in engaging patients in tobacco cessation counseling.

Objectives: To determine whether social support and depressive symptoms mediate the relationship between poverty and substance use in tuberculosis (TB) patients in South Africa. Methods: We performed structural equation modeling with the latent constructs socioeconomic status (SES), social support and "substance use" (tobacco smoking, alcohol problem, illicit drug use) in 1005 male TB patients. Results: Higher SES directly (standardized coefficient= -0.27) and indirectly reduced substance use. Indirectly SES provided increased social support (coefficient=0.37), which was associated with reduced substance use (coefficient=-0.15). Higher SES diminished depressive symptoms. Model fit was acceptable. Separate models for tobacco smoking, illicit drug use or alcohol problem produced similar findings. Conclusions: Poverty alleviation and social support-based interventions may benefit male TB patients with substance use.

Introduction The concurrent use of multiple tobacco products (i.e., poly-tobacco use) might hinder efforts to reduce overall tobacco use, particularly considering that use of some non-cigarette tobacco products may be popular in some regions due to social, cultural, or economic reasons. This study assessed poly-tobacco use patterns among persons aged â?¥15 years old from 44 countries. Methods Data from 44 countries in all six World Health Organization regions were obtained from the 2008-2012 Global Adult Tobacco Surveys (n = 19 countries), and the Special Eurobarometer 385 (77.1) survey, 2012 (n = 25 countries). Correlates of poly-tobacco use were assessed using multivariate logistic regression analyses (p < 0.05). Results Overall prevalence of poly-tobacco use ranged from 0.8% (Mexico) to 11.9% (Denmark). In 28 countries, 20% or more of current smokers of manufactured cigarettes concurrently used at least one other tobacco product and this proportion was highest in India (66.2%) and lowest in Argentina (4.4%). After adjusting for other factors, the likelihood of being a poly-tobacco user among all respondents was lower among females (aOR = 0.09; 95%CI:0.08-0.11), and among respondents from upper-middle-income (aOR = 0.53, 95%CI:0.43-0.66), and lower-middle-income countries (aOR = 0.64; 95%CI:0.51-0.81) compared to high income countries. Increased likelihood of poly-tobacco use was observed among respondents from the South-East Asian region compared to those from the European region (aOR = 1.58, 95%CI:1.35-1.85), as well as among respondents aged â?¥65 years (aOR = 2.10; 95%CI:1.73-2.54), compared to those aged

Introduction. This study assessed the influence of exposure to pro-tobacco advertisements on experimentation with emerging tobacco products among U.S. adolescents aged ≥9 years, in Grades 6 to 12. Method. Data were obtained from the 2011 National Youth Tobacco Survey. Multivariate logistic regression was used to measure the association between experimentation with snus and e-cigarettes and exposure to pro-tobacco advertisements from three sources: over the Internet, in newspapers/magazines, and at retail stores. Results. After controlling for sociodemographic characteristics and current use of other tobacco products, the odds of experimenting with snus were 1.36 (95% confidence interval [CI] = 0.88-3.16), 2.03 (95% CI = 1.30-3.17), and 3.24 (95% CI = 2.07-5.07), among students exposed to one, two, or all three types of pro-tobacco advertisements, respectively, compared with those exposed to none. Similar results were obtained for e-cigarettes. Conclusion. Stronger restrictions on tobacco advertisements, in concert with increased tobacco taxes and warning about the dangers of tobacco, use may help reduce youth tobacco use.

Introduction This study sought to determine the sociodemographic correlates of exclusive and concurrent use of smokeless tobacco (SLT) and smoking (i.e., dual use) and to explore the association between SLT use and the amount of cigarettes smoked per day. Methods Data were obtained from a nationally representative sample of Nigerian men aged 15-59 years (N = 15,453) who participated in the 2008 Nigerian Demographic and Health Survey (NDHS). The NDHS used an interviewer-administered questionnaire to collect data on participants' sociodemographic characteristics and tobacco use status. Taking account of the multistage sampling used in the NDHS, data analyses included descriptive statistics, chi-square analysis, and multivariable adjusted multinomial logistic regression analysis. Results Of the respondents, 12.2% (n = 1,842) were tobacco users, out of which 24.5% (n = 477) were exclusive SLT users, 69% (n = 1,236) were exclusive smokers, and 6.5% (n = 129) were dual users. Both SLT use and smoking were most prevalent among the Igbo ethnic group and among the least educated men. SLT use was most prevalent among those in the southeast (9.75%) and north-central (7.71%) regions, where smoking was also common. The number of cigarettes smoked per day was not significantly different among dual users when compared with exclusive smokers (7.3 vs. 5.6; p = .088). Dual users were also more likely to self-identify as traditionalists (RRR = 6.03; 95% CI = 2.96-12.28) compared with self-identifying as practicing Islam or Christianity. Conclusions There are distinctive ethnic and regional differences in tobacco use patterns among Nigerian men, and SLT use was not associated with reduced smoking intensity among dual users.

Background Oral pain affects people’s daily activities and quality of life. The burden of oral pain may vary across socio-economic positions. Currently, little is known about the social gradient in the cost of oral pain among South Africans. This study therefore assessed the social gradient in the cost of oral pain and the related dental service utilisation pattern among South African adults. Methods Data were obtained from a nationally representative cross-sectional survey of South African adults ≥16 year-old (n = 2651) as part of the South African Social Attitudes Survey conducted by the South African Human Sciences Research Council. The survey included demographic data, individual-level socio-economic position (SEP), self-reported oral health status, past six months’ oral pain experience and cost. The area-level SEP was obtained from the 2010 General Household Survey (n = 25,653 households) and the 2010/2011Quarterly Labour Force Survey conducted in South Africa. The composite indices used for individual-level SEP (α = 0.76) and area-level SEP (α = 0.88) were divided into tertiles. Data analysis was done using t-tests and ANOVA. Significance was set at p

Tobacco use among youth is a major public health problem. Youth outside of formal school settings are often understudied but may be at increased risk.A descriptive cross- sectional study was carried out among 326 young people aged 15-24 years in four randomly selected motor parks in Lagos state. Interviewer-administered questionnaires were used to collect data.The mean age of the respondents was 21.0±2.3yrs. Many 252 (77.3%) dropped out before the end of the third year of secondary schooling. The majority were aware that active (78.2%), and passive smoking (77.3%) are harmful to health. Nearly two-thirds of the respondents disagreed with an outright ban of cigarettes (63.2%) and restriction of cigarette sales to persons below 18 years (67.9%) while 254 (66.8%) supported a ban on tobacco smoking in enclosed public places. One hundred and fifty (46.0%) respondents had experimented with smoking of which 106 (32.5%) had progressed to become current smokers. Half of the current smokers, 54 (50.9%), felt the need for a cigarette first thing in the morning. A multivariate analysis for smoking initiation, showed that for every increasing year of age, respondents were 1.08 times more likely to have initiated cigarette smoking; males and respondents who lived alone or with peers were 2.34 times and 1.77 times more likely to have initiated smoking respectively; those who consume alcohol and marijuana were 7.27 and 1.89 times respectively more likely to have initiated smoking while those who consumed alcohol were 6.17 times more likely to be current smokers.

BACKGROUND: Secondhand smoke (SHS) causes disease and death among nonsmokers. Private settings are major sources of exposure for children. We assessed prevalence and determinants of self-reported SHS exposure in homes and vehicles, as well as school, work, and indoor/outdoor public areas, among US students in grades 6 through 12. METHODS: Data were from the 2013 National Youth Tobacco Survey (n = 18 406). Self-reported SHS exposure within the past 7 days was assessed overall and by extent of smoke-free home and vehicle rules among never users of 10 tobacco product types. Descriptive statistics were used to compare estimates, and adjusted prevalence ratios were calculated to assess determinants of SHS exposure. RESULTS: Among never tobacco users, 48.0% reported SHS exposure in 1 or more locations, including 15.5% in the home, 14.7% in a vehicle, 16.8% at school, 27.1% at work, and 35.2% in an indoor/outdoor public area. Home exposure was 8.5%, 55.3%, and 79.4% among never tobacco users with complete, partial, or no smoke-free home rules, respectively (P < .05). Vehicle exposure was 7.1%, 44.8%, and 70.2% among never tobacco users with complete, partial, or no smoke-free vehicle rules, respectively (P < .05). Factors associated with higher prevalence ratio of SHS exposure included current tobacco use, truant behavior, and having tobacco using household members/friends CONCLUSIONS: Approximately half of US students in grades 6 through 12 reported exposure to SHS in 2013. Smoke-free home and vehicle rules, coupled with intensified implementation and enforcement of comprehensive smoke-free laws, could help protect youth from this preventable health hazard.

Aim: This study examined the influence of the social context in which people live on self-ratings of their oral health. Method: This study involved a representative sample of 2,907 South African adults (≥16 years) who participated in the 2007 South African Social Attitude Survey (SASAS). We used the 2005 General Household Survey (n = 107,987 persons from 28,129 households) to obtain living environment characteristics of SASAS participants, including sources of water and energy, and household cell-phone ownership (a proxy measure for the social network available to them). Information obtained from SASAS included socio-demographic data, respondents’ level of trust in people, oral health behaviors and self-rated oral health. Results: Of the respondents, 76.3% self-rated their oral health as good. Social context influenced women’s self-rated oral health differently from that of men. Good self-rated oral health was significantly higher among non-smokers, employed respondents and women living in areas with higher household cell-phone ownership. Furthermore, trust and higher social position were associated with good self-rated oral health among men and women respectively. Overall, 55.1% and 18.3% of the variance in self-rated oral health were explained by factors operating at the individual and community levels respectively. Conclusion: The findings highlight the potential role of social capital in improving the population’s oral health.

OBJECTIVES To determine factors associated with dual use of tobacco products in a population of black South African adolescents. METHODS Data were obtained from a self-administered questionnaire completed by a representative sample of grade 8 students from 21 randomly selected secondary state schools in the Limpopo Province, South Africa (n=1878). RESULTS Of the respondents, 11.4% used smokeless tobacco (SLT), and 55.2% of SLT users also smoked cigarettes (dual users). Dual users were more likely to be vulnerable to depression, engage in binge drinking, smoke cannabis, and attend schools without rules against smoking. CONCLUSION Dual tobacco use forms part of multiple-risk-taking behavior.

Objective: This study sought to determine the influence of sense of coherence (SOC), a personal stress-coping resource, and smoking on the self-reported gingival health of a cohort of rural black South African adolescents. Methods: This 18-month study involved a three-wave survey of a representative sample of eighth graders from 11 randomly selected high schools in the Limpopo province. South Africa (n = 970). Using a generalized estimating equation model, we examined the correlates of recent gingivitis, defined as self-reporting frequent gingival bleeding (GB). Explanatory variables included baseline socio-economic status, age, gender, plaque levels, toothbrushing frequency, tobacco use status and SOC levels. Results: Among our sample, 74.6% reported experiencing gingivitis at some point during follow-up, while 41.9% reported frequent GB at the last survey. Factors that were positively associated with recent gingivitis include living in poor households [odds ratio (OR) = 1.49; p

This study investigated socio-economic factors associated with the placement of fissure sealants in a population of South African adolescents.The study participants were high school students aged 12 to layers who provided baseline data during 2005 in a tobacco-use prevention trial, and consented to oral examination (n=1103). Information was obtained using a self-administered survey questionnaire, including demographic data, data on oral health behaviour, the employment status of parents/guardians, and the family structure of the household and on health insurance enrolment. The main outcome measure was the presence of a fissure sealant on any tooth, recorded using the WHO oral examination protocol. Data were analysed using chi-square statistics and multiple logistic regression analysis (p0.05).Overall, only 3.5% (n=37) of the study participants had a fissure sealant, and only 31.3% (n=345) had ever made a dental visit. Those who had attended seeking mostly preventive care were significantly more likely to have a fissure sealant than those who had visited mostly when they were in pain (14.2% vs. 2.9%; p0.001). In the multi-variable adjusted analysis, those reporting to have parents who are both employed (OR = 2.76; 2.26 - 3.38), and reporting regular preventive dental visits (OR = 3.55; 2.28 -5.58) were positively associated with receiving fissure sealant, while those who self-identified as black (OR = 0.04; 0.01 - 0.13), were significantly less likely to present with a fissure sealant as compared with other ethnicity/race groups.Higher socio-economic status and regular access to preventive care were significantly associated with the placement of fissure sealants in the studied population.

Cigarette prices have almost doubled in South Africa within the past decade due to pricing/taxation policies. Little is known about the equity impact of these price increases in concert with other tobacco control policies. This study therefore examined trends in current cigarette smoking overall and by socioeconomic status (SES) in South Africa during 2003-2011.Data were obtained from the 2003 (n = 2,855), 2007 (n = 2,907), and 2011 (n = 3,003) South African Social Attitudes Survey. Educational attainment (grade 12, grade 12, grade 1-11, or no education) was used as a proxy for SES, and all analyses were restricted to respondents aged ≥25 years. Trends in current cigarette smoking-defined as daily or some days use of cigarettes-during 2003-2011 were assessed with estimates of annual percentage change (APC), while smoking disparities were assessed with relative concentration index (RCI).Although no significant change was observed in the overall prevalence of current smoking during 2003-2011, declines were observed among those with no education (APC = -8.2; p.05 for linear trend). However, increased smoking was observed among the most educated women (from 4.0% in 2003 to 13.1% in 2011; p.05 for linear trend). The RCI by educational status changed significantly during the study period, from 0.80 (2003) to 1.35 (2007) to 1.94 (2011).The policy environment in South Africa during 2003-2011 had a significant positive equity impact by SES, even though no aggregate change in smoking prevalence was observed. Intensified implementation of taxation measures as part of a comprehensive tobacco control may further reduce smoking disparities.

Traditional healers (THs) exert a significant influence in indigenous South African communities, where smokeless tobacco (SLT) use and dependence is common among women. This study was conducted during 2002. It sought to explore THs' beliefs about SLT use and its health effects. In-depth interviews were conducted with 28--mostly female (68%)--registered THs, with a mean age of 55 years and with an average of 17 years of practice experience. These listed THs were randomly selected from two culturally diverse regions of the (largely rural) Limpopo Province in South Africa. The THs perceive the ritual (external) use of SLT as an absolute necessity in divination, but 32% have also prescribed its 'internal' use to their clients, usually following a "directive from the ancestors." Almost all the THs who themselves regularly consume SLT condemned the recreational use of SLT and believe that SLT is addictive. However, 39% of them claimed to be able to treat addiction resulting from tobacco use not sanctioned by the ancestors. This study has identified opportunities for enlisting THs' collaboration in future community-based tobacco dependence interventions.

Background: Secondhand smoke (SHS) exposure is a well-established health hazard. To determine the effectiveness of existing smoke-free policies and adoption of smoke-free rules in South Africa, we assessed exposure to SHS from several sources among non-smoking adults during 2010. Methods: Data were analyzed for 3,094 adults aged ≥16 years who participated in the 2010 South African Social Attitudes Survey. Descriptive statistics and multivariate analyses were used to assess presence of smoke-free rules among all South Africans, and prevalence and correlates of SHS exposure at work, at home, and at hospitality venues among non-smokers. Results: Overall, 70.6% of all South African adults had 100% smoke-free rules in their private cars, 62.5% in their homes, while 63.9% worked in places with 100% smoke-free policies. Overall, 55.9% of all non-smokers reported exposure to SHS from at least one source (i.e., in the home, workplace or at a hospitality venue). By specific source of exposure, 18.4% reported being exposed to SHS at work, 25.2% at home, 33.4% in a restaurant, and 32.7% at a bar. Presence of work bans on indoor smoking conferred lower likelihood of SHS exposure at work among non-smokers (adjusted odds ratio [aOR] = 0.23; 95% CI: 0.09-0.60). Similarly, smoke-free home rules decreased the odds of being exposed to SHS at home among non-smokers (aOR =0.16; 95% CI: 0.09-0.30). Conclusion: Over half of South African adults reported SHS exposure in the home or at public places such as the workplace and at hospitality venues. This underscores the need for comprehensive smoke-free laws that prohibit smoking in all public indoor areas without exemptions.

Tuberculosis (TB) patients who smoke risk adverse TB outcomes and other long-term health effects of smoking. This study aimed to determine the efficacy of brief motivational interviewing by lay health-care workers (LHCWs) in assisting TB patients to quit smoking.Multi-centre two-group parallel individual randomized controlled trial.Six primary care tuberculosis clinics in a South African township.Newly diagnosed adult TB patients identified as current smokers were randomized to brief motivational interviewing by a LHCW (intervention group, n = 205) or brief smoking cessation advice from a TB nurse (control group, n = 204).The primary outcome was self-reported sustained 6-month smoking abstinence. Exhaled carbon monoxide (CO) testing was offered to about half the participants. Secondary outcomes were sustained abstinence at 3 months; 7-day point prevalence abstinence at 1, 3 and 6 months; and quit attempts. Allocation was concealed. Primary analysis relied on intention to treat. Multi-level analysis accounted for site heterogeneity of effect.Self-reported 6-month sustained abstinence was 21.5% for the intervention group versus 9.3% for the control group [relative risk (RR) = 2.29, 95% confidence interval (CI) = 1.34, 3.92]. Biochemically verified 6-month sustained abstinence was also higher in the intervention group (RR 2.21, 95% CI = 1.08, 4.51) for the 166 participants who were offered carbon monoxide testing. Self-reported 3-month sustained abstinence was 25.4% for the intervention group and 12.8% for the control group (RR = 1.98, 95% CI = 1.24, 3.18).Motivational interviewing by lay counsellors to promote smoking cessation in tuberculosis patients in South Africa approximately doubled sustained smoking abstinence for at least 6 months compared with brief advice alone.

This study assessed differences among health professions students in exposure to didactic tobacco cessation training in asking about patients' tobacco use status ("ask") and assisting smoking patients to quit by providing educational materials ("assist"). Data from the 2005-08 Global Health Professions Student Survey were analyzed for 28,420 medical, dental, nursing, and pharmacy students in eight low- and middle-income countries. Country-specific prevalence of exposure to training in tobacco cessation was calculated for each profession category; differences were assessed using logistic regression analysis (p0.05). The proportion of dental students taught to implement the "ask" intervention ranged from 45.4 percent (Armenia) to 95.2 percent (Chile). Only about one-third of these dental students reported being taught to implement the "assist" intervention in most countries. After adjusting for survey year, country, gender, and tobacco use, the odds of dental students' being taught to implement the "ask" intervention were lower than for medical students (adjusted odds ratio [aOR]=0.63; 95% CI: 0.42-0.96). Similarly, the odds of being taught to implement the "assist" intervention were significantly higher for medical (aOR=1.65; 95% CI: 1.26-2.17), nursing (aOR=2.84; 95% CI: 2.37-3.40), and pharmacy students (aOR=1.36; 95CI:1.05-1.76) than for dental students. These findings underscore the need for enhanced measures to incorporate tobacco cessation training as a formal component of dental education globally.

Cigarette rod length as a design feature may play a specific role in harm perception and tobacco use. Internal tobacco industry documents have shown targeting of females with long/ultra-long cigarettes. This study assessed trends and differences in smoking of long/ultra-long cigarettes among U.S. smokers aged ≥20 years during 1999 through 2012.Data were obtained from the 1999/2000 through 2011/2012 National Health and Nutrition Examination Survey. The proportion of current smokers who reported using long/ultra-long cigarettes during each survey year was calculated and compared using χ(2) statistics. Linear and quadratic trends during 1999 through 2012 were assessed using binary logistic regression (p0.05). Multi-variable analyses were performed to assess current disparities in smoking of long/ultra-long cigarettes.Despite overall declines in current smoking of long/ultra-long cigarettes during the 1999 through 2012 period (p0.001 for both linear and quadratic trends), the proportion of smokers of long/ultra-long brands increased in recent years, with over a third (38.7%) of current smokers reporting smoking of long/ultra-long cigarettes during 2011/2012. Current smokers of long/ultra-long cigarettes were more likely to be female compared to males (aOR=3.09; 95%CI: 2.09-4.58), of black race compared to whites (aOR=2.07; 95%CI: 1.30-3.28), or aged 45-64, or ≥65 years (aOR=2.39 and 5.27, respectively), compared to 18-24 year olds.Specific gender, age and race/ethnic characteristics of smokers of long/ultra-long cigarettes were noted, hence potentially contributing to the widening of health disparities. Cigarette rod length should be considered an important aspect of cigarette engineering/design in regulatory efforts to reduce the burden of tobacco-related disease.

Background Some smokeless tobacco products (SLT) have been shown to be associated with only a fraction of the risks of cigarettes. This study assessed South African smokers’ interest in switching to a hypothetical reduced harm SLT product. Methods The 2007 South African Social Attitudes Survey was analysed for 678 exclusive cigarette smokers. Respondents were asked about their perceptions about relative harm of snuff compared to cigarettes, and their interest in switching to snuff if informed it was 99% less harmful than cigarettes. Results About 49.7% of exclusive cigarette smokers believed that snuff was equally as harmful as cigarettes; 12.9% thought snuff was more harmful; 5.7% thought snuff was less harmful; while 31.8% did not know if there was a difference in harm between snuff and cigarettes. Approximately 24.2% of exclusive cigarette smokers indicated interest in switching to snuff, with significantly greater interest observed among those exposed to 100% smoke-free work environment. Interest in switching was highest (34.7%) among smokers who believed a priori that using snuff was more harmful than cigarettes, and lowest (14.5%) among those who did not know if there was a difference in harm. In a multi-variable adjusted logistic regression model, this latter group remained less likely to be interested in harm reduction switching (adjusted odds ratio = 0.42; 95% CI: 0.19–0.91). Conclusion About a quarter of smokers indicated interest in harm reduction switching to snuff. SLT products have a potential role in reducing the harm from smoking in South Africa, but only if they are not used to circumvent smoke-free laws that have been associated with reduced smoking.

Introduction This study assessed knowledge of South African smokers about nicotine replacement therapy (NRT) and their interest in using it for smoking cessation if it is provided free. Methods The 2007 South African Social Attitudes Survey was analyzed for 689 smokers aged ≥ 16 years. Prevalence of receipt of tobacco cessation counseling from a health care professional as well as self-reported knowledge about NRT was calculated. Multivariable logistic regression was used to assess factors associated with interest in using NRT if provided for free. Results About 26.1% of current smokers reported ever receiving tobacco cessation counselling from a health care professional. Although 67.7% of smokers were aware of NRT, only 3.9% had ever used NRT. However, 77.6% of those aware of NRT were interested in using it for smoking cessation if offered for free. After adjusting for potential confounders, smokers' interest in using NRT was inversely associated with interest in harm-reduction switching to snuff (adjusted odds ratio [AOR] = 0.34; 95% confidence interval [CI] = 0.14-0.80) and also reduced with each unit increase in lifetime duration of smoking (AOR = 0.93; 95% CI = 0.88-0.99). Interest in NRT use was higher among polytobacco users compared with exclusive cigarette smokers (AOR = 10.21; 95% CI = 1.08-96.15) and generally increased with increasing age of smoker. Conclusions About two-thirds of smokers knew about NRT, and the majority were interested in using NRT for smoking cessation if provided free. These findings underscore the need to increase awareness of smokers about NRT through mass-media campaigns as well as include tobacco dependence treatment as part of the national health insurance programs of low- and middle-income countries.

The contradictory results of earlier studies on the role of snuff in the aetiology of oral cancer may be due to the heterogeneous composition of snuff and to regional and cultural differences in its use. The aim of this study was to determine the prevalence and pattern of use of oral snuff in a rural South African adult population, and to report on associated oral lesions. A structured questionnaire was administered by means of face-to-face interviews with a population of 30 randomly selected households (125 adults over the age of 30 years). Of the respondents, 20.8% were active oral snuff-dippers and 80.8% of them had never visited a dentist before. There was no significant difference between the genders of the dippers (P0.05). The mean age of dippers was 62.7 years. None of the snuff-dippers chewed or smoked tobacco, but 38.5% used alcohol. Mean dipping period was 21.5 years, for about 2 hours per day and an average of 35 minutes per dip. Of the snuff-dippers, 84.6% place their snuff in the lower labial sulcus and 15.4% in the lower buccal sulcus, 80.8% of the dippers demonstrated keratotic lesions at the site of placement. The clinical severity of the lesions was significantly associated with the brand of snuff used (P0.01). The high prevalence of snuff dipping and associated lesion in many of the elderly that had never visited a dentist before highlights the importance of regular screening of this group at risk.

Objectives Knowledge of nicotine replacement therapy (NRT) is a competency that is expected from receiving training in the treatment for tobacco dependence. This study therefore assessed the knowledge of dental students in 43 countries about NRT. Methods The 2005–2011 dental Global Health Professions Student Survey data were analysed for 13,040 third-year dental students from 43 countries. Knowledge about NRT was self-reported and country-specific prevalence estimates were calculated. To assess for correlates of knowledge about NRT amongst dental students, a multivariate logistic regression model was fitted (P

Purpose This study compared data from 32 countries to assess predictors and patterns of cigarette and smokeless tobacco (SLT) use among students aged 13–15 years old. Methods Data from the 2007–2008 Global Youth Tobacco Surveys were analyzed for students aged 13–15 years in 31 countries located in all six World Health Organization regions. In addition, the 2011 National Youth Tobacco Survey was analyzed for U.S. students aged 13–15 years. Country-specific prevalence of current smoking, current SLT use, and concurrent use patterns were assessed. Results The national prevalence of current cigarette smoking among students aged 13–15 years ranged from 1.8% (Rwanda) to 32.9% (Latvia), whereas current SLT use ranged from 1.1% (Montenegro) to 14.4% (Lesotho). In the U.S. and most European countries surveyed, current smoking prevalence was significantly higher than SLT prevalence, in contrast to patterns observed in low- and middle-income countries. Also, in most of the surveyed countries outside of Europe and the United States, SLT use among girls was as common as their use of cigarettes, and not significantly different from use by boys. When compared with U.S. adolescents, the odds of SLT use were highest among African adolescents (adjusted odds ratio = 3.98; 95% CI: 2.19–7.24) followed by those in the Southeast Asian region (adjusted odds ratio = 2.76; 95% CI: 1.38–5.53). Conclusions Region-specific patterns of tobacco use were noticed. Furthermore, it is alarming that in several low- and middle-income countries, the prevalence of SLT use among females did not differ from that among males, suggesting the possibility of a future shared burden of disease between both males and females.

The study aimed to describe the demographic profile of children receiving dental general anaesthesia (DGA) at the Pretoria Oral-and-Dental Hospital, South Africa, the type of treatment received and the level of compliance with the six-month preventive follow-up visit.Retrospective review of records of children treated under DGA between January 2009 and December 2010.The study group contained 78-children. Of these, 79.5% were between one and four years of age (mean 3.7-years; SD: 2.01), and 54% were female. The parents of more than half the sample (56.4%) were unemployed. The majority (55.2%) recorded no medical condition prior to undergoing DGA. Of the treatments performed, 63% were extractions (mean = 4.7 teeth/child), 51% involved placement of composite restorations (mean = 3.4 teeth) and 18% were fitting of stainless steel crowns (mean = 2.1 teeth). No preventive treatment was performed under DGA. Only 14 children (18%) returned within 15-months for follow-ups. Seven returnees were re-booked for a second DGA appointment for severely carious teeth; the rest received preventive treatment. Female children (Odds Ratio (OR): 0.28; p = 0.04) and children with no medical-condition (OR: 0.20; p = 0.03) were less likely to return for a follow-up visit. Children with employed parents were more likely (OR: 3.50; p = 0.09) to return for follow-ups.This study highlights the importance of preventive treatment prior to and during DGA, especially in a setting where the caries disease burden and unemployment are high.

Introduction This study assessed the perceptions and behaviors of US adults about the security of their protected health information (PHI). Methods The first cycle of the fourth wave of the Health Information National Trends Survey was analyzed to assess respondents' concerns about PHI breaches. Multivariate logistic regression was used to assess the effect of such concerns on disclosure of sensitive medical information to a healthcare professional (p

OBJECTIVES: To assess the prevalence and correlates of use of conventional and novel smokeless tobacco products among a national sample of US middle and high school students. METHODS: Data from the 2011 National Youth Tobacco Survey were analyzed to determine national estimates of current use of conventional (“chewing tobacco”, “snuff,” or “dip”), novel (“snus” and “dissolvable tobacco products”), and any smokeless tobacco products (novel and/or conventional products) within the past 30 days. RESULTS: The overall prevalence of current use of any smokeless tobacco product was 5.6% (n = 960). Among all students, 5.0% used chewing tobacco, snuff, or dip; 1.9% used snus; and 0.3% used dissolvable tobacco products. Among users of any smokeless tobacco, 64.0% used only conventional products, 26.8% were concurrent users of novel plus conventional products, whereas 9.2% exclusively used novel products. Approximately 72.1% of current any smokeless tobacco users concurrently smoked combustible tobacco products, and only 40.1% expressed an intention to quit all tobacco use. Regression analyses indicated that peer (adjusted odds ratio [aOR]: 9.56; 95% confidence interval [CI]: 7.14–12.80) and household (aOR: 3.32; 95% CI: 2.23–4.95) smokeless tobacco use were associated with smokeless tobacco use, whereas believing that all forms of tobacco are harmful was protective (aOR: 0.55; 95% CI: 0.38–0.79). CONCLUSIONS: Conventional smokeless tobacco products remain the predominant form of smokeless tobacco use. Most users of novel smokeless tobacco products also concurrently smoked combustible tobacco products. Smokeless tobacco use was associated with lower perception of harm from all tobacco products and protobacco social influences, indicating the need to change youth perceptions about the use of all tobacco products and to engage pediatricians in tobacco use prevention and cessation interventions.

Background Evidence suggests that healthcare providers (HCPs) in South Africa do not consistently offer tobacco dependence treatment (TDT) during clinical consultations. In order to understand and explain this behaviour in a South African context, we conducted a qualitative exploration of HCPs’ experiences, perceptions and behaviours regarding TDT. Methods Individual qualitative interviews were conducted with physicians and nurses who were purposively selected. Themes were identified from interview transcripts using content analysis. Findings were triangulated and peer-reviewed, and were also verified by the participants. Results Fifteen physicians and four nurses were interviewed, none of whom used tobacco. These participants perceived TDT as an important task, but could not consistently implement it during clinical consultations due to health systems constraints (time-constraints because of patient-overload, the unavailability of cessation medications and a lack of support for referrals), misperceptions and misconceptions (negative outcome expectations about the effectiveness and feasibility of TDT), socio-cultural barriers (counselling older persons was perceived as challenging) and personal limitations (perceived low self-efficacy, poor knowledge and skills on implementing any evidence-based TDT framework). Patients are therefore selectively screened based on clinical relevance and offered only prescriptive brief advice. Participants recommended several systems changes, including academic detailing of tobacco status, training HCPs and incorporating tobacco cessation medications in the Essential Drug List. Conclusion The reported selective screening and limited TDT interventions offered by HCPs are related to interactions between health systems constraints, personal limitations, and misperceptions and misconceptions about the effectiveness and feasibility of TDT during clinical consultation. Implementing the recommended systems changes has the potential to improve the implementation of TDT in South African primary health care (PHC).

Background: Tuberculosis (TB) patients who smoke tobacco are at an increased risk for adverse TB treatment outcomes. This study describes tobacco use patterns among newly diagnosed TB patients, their readiness to quit, and their beliefs about tobacco-related health effects in a high HIV-burden setting in South Africa. Socio-economic and demographic factors associated with smoking were also determined. Methods: This was a cross-sectional analysis of baseline data collected for a smoking cessation study at six large tuberculosis clinics in a South African township (N = 1926). We collected information on current and past tobacco use, socio-economic and demographic status, beliefs regarding the harmful effects of smoking and quit behaviour, and motivation, using structured interviewer-administered questionnaires. TB- and HIV-related information was obtained from patient records. Data analysis entailed descriptive statistics, followed by multivariate logistic regression with backward elimination, adjusted for clustering by facility. Results: Just over one fifth of respondents (21.8%, 420/1924) reported currently smoking tobacco (males 37.6%, females 4.6%). By contrast, only 1.8% (35/1918) of all respondents reported being past smokers. Of the current smokers, about half (51.8%, 211/407) had previously attempted to quit, mainly for health reasons. The majority of respondents (89.3%, 1675/1875) believed tobacco smoking was harmful for their health and smokers were highly motivated to quit (median score 9, interquartile range 7–10). Smoking was less common among female respondents (Odds Ratio [OR] 0.10, 95% Confidence Interval [CI] 0.06-0.19) and respondents who had completed high school (OR 0.57, 95% CI 0.39-0.84), but was more common among respondents who do occasional work (OR 2.82, 95% CI 1.58-5.02), respondents who to bed hungry regularly (OR 4.19, 95% CI 2.42-7.25), those who have an alcohol problem (OR 5.79, 95% CI 3.24-10.34) and those who use illicit substances (OR 10.81, 95% CI 4.62-25.3). Conclusions: Despite documented evidence of its harmful effects, smoking is prevalent among male TB patients in this high HIV-prevalence population. Few patients have managed to quit smoking on their own. However, patients are highly motivated to stop smoking. We recommend implementing and evaluating a smoking cessation programme in tandem with TB services.

Background The prevalence of smoking and consumption of cigarettes have decreased in South Africa over the last 20 years. This decrease is a result of comprehensive tobacco control legislation, particularly large cigarette tax increases. However, little attention has been given to the potential use of ‘roll-your-own’ cigarettes as cheaper alternatives, especially among the socio-economically disadvantaged population. This study therefore sought to determine socio-demographic correlates of ‘roll-your-own’ cigarette use among South African adults (2007–2010). Methods This secondary data analysis used a merged dataset from two nationally representative samples of 2 907 and 3 112 South African adults (aged ≥16 years) who participated in the 2007 and 2010 annual South African Social Attitude Surveys respectively. The surveys used a face-to-face interviewer-administered questionnaire. The overall response rates were 83.1% for 2007 and 88.9% for 2010. Data elicited included socio-demographic data, current smoking status, type of tobacco products used, past quit attempts and self-efficacy in quitting. Data analysis included chi-square statistics and multi-variable adjusted logistic regression analysis. Results Of the 1 296 current smokers in this study, 24.1% (n = 306) reported using roll-your-own cigarettes. Some of whom also smoked factory-made cigarettes. Roll-your-own cigarette smoking was most common among black Africans and was more common among male smokers than among female smokers (27% vs 15.8%; p