Standardizing surveillance and monitoring processes to measure worldwide tobacco use
Tobacco use is responsible for about one in every 10 adult deaths worldwide and inflicts chronic illness on millions more. Before 2007, there was no standard protocol for tracking and monitoring the tobacco epidemic that would provide national estimates able to be compared across countries.
In support of global efforts to lessen the burden of tobacco-related disease, RTI provides technical assistance for the design and implementation of the Global Adult Tobacco Survey (GATS). GATS collects household-level data on tobacco use from adults aged 15 years and older in low- and middle-income countries, and has been validated as a new standard for tobacco studies.
Determining the Depth of the Problem
Initiated in partnership with the World Health Organization (WHO), the U.S. Centers for Disease Control and Prevention (CDC), the Johns Hopkins Bloomberg School of Public Health, the CDC Foundation, and other partners, the Global Tobacco Surveillance System (GTSS) aims to enhance countries’ capacity in establishing youth and adult tobacco control surveillance and monitoring programs.
One of four surveys that are part of GTSS, GATS was developed in 2007 to begin a process for standardized global adult monitoring with the intent to generate internationally comparable data. GATS findings provide countries with data that can be used to better inform the design, implementation, and evaluation of tobacco intervention efforts. GATS estimates also indirectly measure the impact of tobacco control and prevention strategies outlined in the WHO Framework Convention on Tobacco Control (WHO FCTC), a global health treaty, and MPOWER, a six-part strategy to help implement country-level interventions aimed at reducing tobacco demand.
In 2007, RTI worked in collaboration with WHO and CDC to provide technical assistance for the design and implementation of the GATS standard process and protocol, which collects household-level tobacco use data on individuals aged 15 years and older in low- and middle-income countries. This included providing a software platform for collecting survey data on a variety of mobile devices, including Android tablets. In 2008 and 2009, the first wave of GATS was conducted in 14 low- and middle-income countries that had high numbers of tobacco users.
With questions covering 15 indicators of tobacco use and key tobacco control measures that correspond to the MPOWER strategies, GATS paints a comprehensive picture of tobacco use, including what types of products are used, how often, at what age participants started using tobacco, and whether they intend to quit. It also includes information on policies and interventions related to secondhand smoke, cessation, anti-tobacco marketing (such as media campaigns and health warning labels), pro-tobacco marketing, economics, and knowledge and perceptions.
After the completion of the first wave of GATS, we know that men are generally more likely to smoke than women, though the difference between the sexes was much higher in some countries than in others. In addition to being more likely to smoke, men also generally start smoking at a younger age than women, although GATS indicates that initiation among women is trending younger in many countries.
China and India led all nations in total smokers, with more than 300 million in China and about 275 million in India. India also dominates the smokeless tobacco population, accounting for almost 206 million of the 247 million total users. Combining the data from GATS with data from similar studies in the United States and United Kingdom revealed that about 852 million of the roughly 3 billion people living in these 16 countries use some form of smoked tobacco.
Validating a New Standard for Tobacco Studies
Following the success of the first wave, GATS has proven effective for collecting nationally representative data and is currently active in 36 countries. Combined with data collected in the United States, the United Kingdom, and other higher-income countries, we now have standardized tobacco use surveillance and monitoring for approximately half of the world’s population. This allows us to track trends, especially as member nations develop, execute, and evaluate tobacco cessation and prevention campaigns. Data from GATS can also inform global noncommunicable disease targets, including the WHO’s global voluntary tobacco target of a 30 percent relative reduction, and public health interventions such as MPOWER.
In the 27 countries that have released GATS data to date, approximately 4,600 fieldworkers have been trained and supplied with 3,500 handheld and laptop computers. They have completed more than 360,000 household screening interviews, using a total of 1,800 survey questions in more than 40 languages and dialects.
As an added benefit, these participating countries are now able to use the technology and experience gained through GATS to improve their capacity to conduct other studies. For example, in support of GATS, we developed a mobile device-based system for collecting data and trained in-country staff on how to use it. We also created a suite of PC-based tools for developing questionnaires, aggregating data, running reports, and generating output analysis files.
In the coming years, we will continue to support this important global surveillance effort, providing technical assistance to participating countries that conduct repeat studies and to new countries that commit to implementing the GATS project.
- CDC and CDC Foundation