East Tennessee State University Digital Commons @ East Tennessee State University Electronic Theses and Dissertations Student Works 5-2016 Assessing Adult Tobacco Smoking Cessation in Low-and-Middle Income Countries: Analysis of the Global Adult Tobacco Survey Data, 2009 – 2012 Daniel Owusu East Tennessee State Universtiy Follow this and additional works at: https://dc.etsu.edu/etd Part of the Epidemiology Commons Recommended Citation Owusu, Daniel, "Assessing Adult Tobacco Smoking Cessation in Low-and-Middle Income Countries: Analysis of the Global Adult Tobacco Survey Data, 2009 – 2012" (2016). Electronic Theses and Dissertations. Paper 3063. https://dc.etsu.edu/etd/3063 This Dissertation - Open Access is brought to you for free and open access by the Student Works at Digital Commons @ East Tennessee State University. It has been accepted for inclusion in Electronic Theses and Dissertations by an authorized administrator of Digital Commons @ East Tennessee State University. For more information, please contact [email protected]. Assessing Adult Tobacco Smoking Cessation in Low-and-Middle Income Countries: Analysis of the Global Adult Tobacco Survey Data, 2009 – 2012 _______________________ A dissertation presented to the faculty of the Department of Biostatistics and Epidemiology East Tennessee State University In partial fulfillment of the requirements for the degree Doctor of Public Health with concentration in Epidemiology _______________________ by Daniel Owusu May 2016 __________________ Dr. Megan Quinn, Chair Dr. Hadii M. Mamudu Dr. Ke-Sheng Wang Dr. Sreenivas P. Veeranki Keywords: Tobacco smoking cessation, low-and-middle income countries, cessation assistance, home smoking rule, intention to quit, advice to quit ABSTRACT Assessing Adult Tobacco Smoking Cessation in Low-and-Middle Income Countries: Analysis of the Global Adult Tobacco Survey Data, 2009 – 2012 by Daniel Owusu Smoking cessation can reduce health risk and prevent millions of tobacco-related deaths. However, cessation rates are low in low-and-middle income countries (LMICs), with only a small proportion of smokers intending to quit. Given the paucity of literature to support tobacco cessation programs in LMICs, this study aimed to: 1) identify factors associated with intention to quit smoking, 2) assess the relationship between health care provider quit advice/tobacco screening and utilization of cessation assistance, and 3) examine the relationship between home smoking rule and smoking intensity across three stages of smoking cessation (precontemplation, contemplation and preparation) in LMICs. Data were obtained from the Global Adult Tobacco Survey, 2009-2012, a nationally representative household survey of noninstitutionalized civilians aged 15 years and older. Weighted multivariable regression analyses were conducted using SAS version 9.4. Adjusted odds ratios (OR), percent change in smoking intensity and associated 95% confidence intervals (CI) were estimated. Home smoking rule and exposure to anti-smoking messages were the important factors associated with contemplation and preparation to quit smoking. Approximately 1%, 7%, 9% and 15% used quitline, medical treatment, counseling/cessation clinic and cessation assistance (all three combined), respectively, in the past year. Quit advice was significantly associated with utilization of counseling/cessation clinic (OR=3.89, 95% CI=2.8–5.5), medical treatment (OR=1.71, 95% CI=1.2–2.4) and cessation 2 assistance (OR=2.60, 95% CI=2.0–3.4). Tobacco screening was associated with utilization of counseling/cessation clinic (OR=2.60, 95% CI=1.1–5.9) and medical treatment (OR=1.71, 95% CI=1.2–2.4). Living in a completely smoke-free home was associated with a 22.5% (95% CI=17.1%–28.0%), an 18.6% (95% CI=9.0%–28.2%), and a 19.4% (95% CI=3.9%–34.9%) significant reduction in smoking intensity among smokers in precontemplation, contemplation and preparation, respectively. In conclusion, the results suggest that smoke-free home, anti- smoking campaigns, and health care provider intervention promote smoking cessation in LMICs. Therefore, comprehensive smoke-free policies, anti-smoking media campaigns and integration of tobacco screening and quit advice into the health care system are important for tobacco cessation in LMICs, suggesting the need for full implementation of the World Health Organization Framework Convention for Tobacco Control Articles 8 and 11 – 13. 3 Copyright 2016 by Daniel Owusu. All Rights Reserved. 4 DEDICATION I dedicate this dissertation to my brothers, Nicholas Obeng, Martin Owusu and Stephen Owusu who contributed generously to my formal education. I owe my educational accomplishments to their financial support, inspiration, and encouragement. 5 ACKNOWLEDGEMENTS I give glory, honor and praises to the Almighty God in the name of our Lord and Savior Jesus Christ. I sincerely acknowledge the favor of God that has seen me through to this level of my educational pursuit. I am indebted to all the faculty and staff of the College of Public Health, East Tennessee State University (ETSU), especially, my Dissertation Committee: Dr. Megan Quinn, Dr. Kesheng Wang, Dr. Hadii M. Mamudu and Dr. Sreenivas P. Veeranki for their immense support. My special appreciation to my Advisor and Dissertation Committee Chair, Dr. Megan Quinn for her wonderful guidance throughout my program. My special thanks also go to my research mentors, Dr. Kesheng Wang and Dr. Mamudu for their great mentoring which has greatly helped to improve my research skills. Dr. Wang’s mentoring in data management and analysis, and manuscript writing since the beginning of my program proved very consequential in this dissertation. Dr. Mamudu has made immeasurable contribution to my training by providing great mentoring in tobacco control research which has resulted in this dissertation. I also want to acknowledge Dr. Shimin Zheng for opening his doors for me, even outside school hours. Dr. Zheng never hesitated to assist with my statistical needs any time I called on him. I sincerely thank Dr. Lazarous Mbulo of the Center for Disease Control and Prevention, and the Global Adult Tobacco Survey (GATS) Collaborative Group for their support and guidance in using the GATS data. My appreciations also go to Ms. Jocelyn Aibangbee, Ms. Oluwatosin Ariyo and Mr. Joseph Kusi, graduate students of the College of Public of Health, ETSU for proofreading parts 6 of the dissertation for me. Their corrections and suggestions were very useful for the improvement of this research. I want to express my heartfelt appreciations to my brothers, Nicholas Obeng, Martin Owusu and Stephen Owusu, who have been the main financiers of my formal education. May God richly bless them. Last but not the least, I am very grateful to my wife, Edith Frimpong for her support and patience. She did not only encourage and inspire me to pursue doctoral degree but also provided material and emotional supports throughout the program. 7 TABLE OF CONTENTS Page ABSTRACT .................................................................................................................................... 2 DEDICATION ................................................................................................................................ 5 ACKNOWLEDGEMENTS ............................................................................................................ 6 LIST OF TABLES ........................................................................................................................ 12 LIST OF FIGURES ...................................................................................................................... 13 ACRONYMS AND ABBREVIATIONS ..................................................................................... 14 Chapter 1. INTRODUCTION .................................................................................................................... 15 Problem Statement .................................................................................................................... 15 Significance of the Study ....................................................................................................... 18 History of Tobacco Use............................................................................................................. 19 Health Impact of Tobacco Use .................................................................................................. 21 Economic Impact of Tobacco Use ............................................................................................ 23 Tobacco Control ........................................................................................................................ 25 Tobacco Cessation..................................................................................................................... 29 Benefits of Tobacco Cessation .............................................................................................. 29 Tobacco Cessation Interventions ........................................................................................... 32 Intention to Quit Smoking ..................................................................................................... 35 8 Health Care Providers’ Role in Tobacco Cessation .............................................................. 37 Smoke-Free Policies and Smoking Cessation ....................................................................... 40 Tobacco Cessation in Low-and-Middle Income Countries (LMICs) ...................................