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ADDRESSING THE TOBACCO EPIDEMIC IN LOW AND MIDDLE INCOME COUNTRIES: BEST PRACTICES THAT REDUCE THE IMPACT OF TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP By LORNA MCLEOD ENGLISH (Under the Direction of Joel Lee) ABSTRACT Tobacco use is leading cause of preventable death in the world. The World Health Organization (WHO) projects that by 2030 tobacco use will kill over 8 million people annually. Eighty percent of the world’s smokers now live in low and middle income countries (LMIC) compared to 20 percent in developed countries. A primary reason for increased smoking in these countries is the tobacco industry’s targeted and aggressive marketing of cigarettes; billions of dollars are spent annually on tobacco advertising, promotion and sponsorship (TAPS). In 2003, the WHO negotiated the Framework Convention on Tobacco Control (FCTC) to prevent the death and disease associated with tobacco use. The FCTC treaty calls for countries to enact comprehensive policies that ban TAPS and inform their populations about dangers of tobacco use. The treaty is founded on proven interventions that countries can implement to protect their population from the epidemic. The objective of this research is to examine tobacco-related policies in LMIC to assess their impact on smoking behaviors. The first study reviewed the impact of TAPS exposure and anti-TAPS policies on students’ smoking behavior in African LMIC. The second study examined the impact of anti-TAPS policies and counter-tobacco messages on male smoking behavior in Thailand and Turkey. The findings suggest that there is an association between TAPS exposure and increased smoking and susceptibility in the youth studied. It was determined that strong anti-TAPS laws are associated with decreased student exposure to advertising and sponsorship, while weak anti- TAPS laws had no impact on exposure level. Further, weak anti-TAPS policies were associated with increased smoking behavior while strong-anti-TAPS policies were suggestive of decrease smoking. Finally, the findings demonstrate that effective enforcement of strong anti-TAPS policies over time can result in improved tobacco control outcomes in middle-income countries where smoking rates are high and tobacco use ingrained in the culture. These findings provide recommendations to improve the effectiveness of tobacco control policies in LMIC. The global effort to regulate tobacco marketing and warn populations about the dangers of smoking is a vital and effective component of tobacco control that must be adopted by LMIC governments. INDEX WORDS: Tobacco use, Smoking, Tobacco advertising promotion sponsorship, TAPS, Anti-tobacco advertising, Counter-tobacco, Tobacco policies, FCTC, Tobacco Control, Youth smoking, Africa tobacco control, Turkey tobacco control, Thailand tobacco control, Tobacco Industry ADDRESSING THE TOBACCO EPIDEMIC IN LOW AND MIDDLE INCOME COUNTRIES: BEST PRACTICES THAT REDUCE THE IMPACT OF TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP By LORNA MCLEOD ENGLISH BS, HUNTER COLLEGE, 1980 MS, LONG ISLAND UNIVERITY, 1987 A Dissertation Submitted to the Graduate Faculty of the University of Georgia in Partial Fulfillment of the Requirements for the Degree DOCTOR OF PUBLIC HEALTH ATHENS, GEORGIA 2014 © 2014 Lorna McLeod English All Rights Reserved ADDRESSING THE TOBACCO EPIDEMIC IN LOW AND MIDDLE INCOME COUNTRIES: BEST PRACTICES THAT REDUCE THE IMPACT OF TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP By LORNA MCLEOD ENGLISH Major Professor: Joel Lee Committee: Neale Chumbler Jessica Muilenburg Jason Hsia Samira Asma Electronic Version Approved: Maureen Grasso Dean of the Graduate School The University of Georgia May 2014 DEDICATION I dedicate this dissertation to my family: To my inspiring mother, Calpurnia McLeod, for instilling in me the importance of hard work and reaching for my goals; to my father, Syrenius McLeod, for his abiding faith in me; to my husband, Clarett English, for unselfishly providing the support and space required to achieve this goal; to my lovely children, Matthew and RaeChelle, who keep me energized and motivated; to my dear sister, Ava and her children, Iman and Jamar, my niece Ayanna and nephew Tafari, for their enthusiastic encouragement; and finally, to my Decatur church family for unceasing prayers on my behalf. To my wonderful extensive village of family and friends, I thank you sincerely – my success is due to your unwavering love and support – God bless you. iv ACKNOWLEDGEMENTS I wish to acknowledge the esteemed members of my Advisory Committee for generously sharing their time and expertise with me in the completion of this research study. Special thanks to Dr. Joel Lee, my Major Professor, for the countless hours of review, reflection and revisions; also to Dr. Jason Hsia for the intense statistical tutoring sessions and sage advice; sincere thanks to Dr. Neale Chumbler, Dr. Jessica Muilenburg, and Dr. Samira Asma for agreeing to serve on my committee. I would also like to acknowledge and thank my colleagues at the Centers for Disease Control and Prevention for allowing me to conduct this research and for providing the required resources. Special thanks to Ann Malarcher, Candace Kirksey Jones, and Linda Andes for providing their expertise and assistance. In addition, I sincerely appreciate the Division’s administrative staff, particularly Earthlyn Graham, Giselle Terrell, and Marcella Lottie, for their continuous support and encouragement throughout this process. Finally, beyond the love and support of my family, this would not have been possible without the constant, sustaining love and power of God. To God be the glory. v TABLE OF CONTENTS Page ACKNOWLEDGEMENTS .............................................................................................................v CHAPTER 1 INTRODUCTION .........................................................................................................1 1.0 Overview ............................................................................................................1 1.1 The Tobacco Epidemic ......................................................................................1 1.2 The Framework Convention on Tobacco Control .............................................2 1.3 Tobacco Advertising, Promotion and Sponsorship/Counter Advertising ..........4 1.4 Focus on Cigarette Smoking ..............................................................................8 1.5 Purpose of Research ...........................................................................................8 1.6 Research Design.................................................................................................9 1.7 Country Backgrounds and Profiles ..................................................................14 1.8 Summary ..........................................................................................................31 2 LITERATURE REVEIW ............................................................................................33 2.0 Literature Review Part One. ............................................................................33 2.1 Literature Review Part Two ............................................................................54 3 THE IMPACT OF TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP EXPOSURE .....................................................................................71 3.0 Abstract ............................................................................................................72 3.1 Introduction ......................................................................................................74 3.2 Background ......................................................................................................77 vi 3.3 Country TAPS Policy and Tobacco Use ..........................................................79 3.4 Methods............................................................................................................82 3.5 Results ..............................................................................................................86 3.6 Discussion .....................................................................................................101 3.7 References ......................................................................................................110 4 AN ASSESSMENT OF POLICIES THAT BAN TOBACCO ADVERTISING, PROMOTION, AND SPONSORSHIP .....................................................................116 4.0 Abstract ..........................................................................................................117 4.1Introduction .....................................................................................................119 4.2 Background ...................................................................................................123 4.3 Methods..........................................................................................................131 4.4 Results ...........................................................................................................134 4.5 Discussion ......................................................................................................140 4.6 Conclusion .....................................................................................................144 4.7 References ......................................................................................................148 5 CONCLUSION .........................................................................................................155