Evolution of the joint International Atomic Energy Agency (IAEA), International Agency for Research on Cancer (IARC), and WHO cancer control assessments (imPACT Reviews).

Before 2005, cancer and other non-communicable diseases were not yet health and development agenda priorities. Since the 2005 World Health Assembly Resolution, which encouraged WHO, the International Agency for Research on Cancer (IARC), and the International Atomic Energy Agency (IAEA) to jointly work on cancer control, progress was achieved in low-income and middle-income countries on a small scale. Recently, rapid acceleration in UN collaboration and global cancer activities has focused attention in global cancer control. This Policy Review presents the evolution of the IAEA, IARC, and WHO joint advisory service to help countries assess needs and capacities throughout the comprehensive cancer control continuum. We also highlight examples per country, showcasing a snapshot of global good practices to foster an exchange of experiences for continuous improvement in the integrated mission of Programme of Action for Cancer Therapy (imPACT) reviews and follow-up support. The future success of progress in cancer control lies in the high-level political and financial commitments. Linking the improvement of cancer services to the strengthening of health systems after the COVID-19 pandemic will also ensure ongoing advances in the delivery of care across the cancer control continuum.

Framing rehabilitation through health policy and systems research: priorities for strengthening rehabilitation.

BACKGROUND: Recent estimates report that 2.4 billion people with health conditions globally could benefit from rehabilitation. While the benefits of rehabilitation for individuals and society have been described in the literature, many individuals, especially in low- and middle-income countries do not have access to quality rehabilitation. As the need for rehabilitation continues to increase, it is crucial that health systems are adequately prepared to meet this need. Practice- and policy-relevant evidence plays an important role in health systems strengthening efforts. The aim of this paper is to report on the outcome of a global consultative process to advance the development of a research framework to stimulate health policy and systems research (HPSR) for rehabilitation, in order to generate evidence needed by key stakeholders. METHODS: A multi-stakeholder participatory technical consultation was convened by WHO to develop a research framework. This meeting included participants from selected Member States, rehabilitation experts, HPSR experts, public health researchers, civil society and other stakeholders from around the world. The meeting focused on introducing systems approaches to stakeholders and deliberating on priority rehabilitation issues in health systems. Participants were allocated to one of four multi-stakeholder groups with a facilitator to guide the structured technical consultations. Qualitative data in the form of written responses to guiding questions were collected during the structured technical consultations. A technical working group was then established to analyse the data and extract its emerging themes. This informed the development of the HPSR framework for rehabilitation and a selection of preliminary research questions that exemplify how the framework might be used. RESULTS: A total of 123 individuals participated in the multi-stakeholder technical consultations. The elaborated framework is informed by an ecological model and puts forth elements of the six WHO traditional building blocks of the health system, while emphasizing additional components pertinent to rehabilitation, such as political priority, engagement and participatory approaches, and considerations regarding demand and access. Importantly, the framework highlights the multilevel interactions needed across health systems in order to strengthen rehabilitation. Additionally, an initial set of research questions was proposed as a primer for how the framework might be used. CONCLUSIONS: Strengthening health systems to meet the increasing need for rehabilitation will require undertaking more HPSR to inform the integration of rehabilitation into health systems globally. We anticipate that the proposed framework and the emerging research questions will support countries in their quest to increase access to rehabilitation for their populations.

Cervical cancer testing among women aged 30-49 years in the WHO European Region.

BACKGROUND: Screening programs play an important role in a comprehensive strategy to prevent cervical cancer, a leading cause of death among women of reproductive age. Unfortunately, there is a dearth of information about rates of cervical cancer testing, particularly in Eastern Europe and Central Asia where levels of cervical cancer are among the highest in the WHO European Region. The purpose of this article is to report on the lifetime prevalence of cervical cancer testing among females aged 30-49 years from across the WHO European region, and to describe high-level geographic and socioeconomic differences. METHODS: We used data from the European Health Information Survey and the WHO STEPwise approach to Surveillance survey to calculate the proportions of women who were tested for cervical cancer. RESULTS: The percentage of tested women ranged from 11.7% in Azerbaijan to 98.4% in Finland, with the lowest percentages observed in Azerbaijan, Tajikistan and Uzbekistan. Testing was lower in Eastern Europe (compared to Western Europe), among low-income countries and among women with lower levels of education. CONCLUSION: Effective cervical cancer screening programs are one part of a larger strategy, which must also include national scale-up of human papilloma virus vaccination, screening and treatment.

A comparison of self-reported to cotinine-detected smoking status among adults in Georgia.

BACKGROUND: Self-reported measures of tobacco use may have limited validity, particularly among some populations. This study aims to validate self-reported smoking measures among Georgian adults participating in the 2016 STEPS survey using cotinine biomarker measurements, and to explore potential differences according to sociodemographic characteristics. Additionally, this paper examines how the estimated prevalence of smoking in the population varies according to measurement type. METHODS: Using the WHO standardized STEPS methodology, adults self-reported their smoking status. In a later stage of the survey, a subset of participants provided a urine sample, which was tested for cotinine. Using each participant's objective cotinine measurement and their self-reported smoking status, we calculated the sensitivity, specificity and positive predictive value of self-reported smoking. Next, we calculated the estimated prevalence of smokers according to the type of measurement. RESULTS: Results indicated high sensitivity (83.37%, 95% CI: 76.79-88.37%) among males and relatively low sensitivity (38.60% CI: 29.23-48.90%) among females. According to self-report, the prevalence of smokers was 26.44% (23.61-29.48%), while according to cotinine detection, the prevalence of smokers was 32.27% (29.16-35.55%). Among all subgroups, the self-reported prevalence of smoking was significantly lower than the cotinine-detected prevalence. CONCLUSIONS: To the best of our knowledge, this is the first time that the validity of the STEPS self-reported tobacco indicator has been tested. Self-reported measures of smoking status may lead to an under-estimation of smoking prevalence among Georgian adults, especially women. These findings suggest that integration of biochemical measures of smoking into tobacco use studies may be an important investment.

Modelling impacts of food industry co-regulation on noncommunicable disease mortality, Portugal.

OBJECTIVE: To model the reduction in premature deaths attributed to noncommunicable diseases if targets for reformulation of processed food agreed between the Portuguese health ministry and the food industry were met. METHODS: The 2015 co-regulation agreement sets voluntary targets for reducing sugar, salt and trans-fatty acids in a range of products by 2021. We obtained government data on dietary intake in 2015-2016 and on population structure and deaths from four major noncommunicable diseases over 1990-2016. We used the Preventable Risk Integrated ModEl tool to estimate the deaths averted if reformulation targets were met in full. We projected future trends in noncommunicable disease deaths using regression modelling and assessed whether Portugal was on track to reduce baseline premature deaths from noncommunicable diseases in the year 2010 by 25% by 2025, and by 30% before 2030. FINDINGS: If reformulation targets were met, we projected reductions in intake in 2015-2016 for salt from 7.6 g/day to 7.1 g/day; in total energy from 1911 kcal/day to 1897 kcal/day due to reduced sugar intake; and in total fat (% total energy) from 30.4% to 30.3% due to reduced trans-fat intake. This consumption profile would result in 248 fewer premature noncommunicable disease deaths (95% CI: 178 to 318) in 2016. We projected that full implementation of the industry agreement would reduce the risk of premature death from 11.0% in 2016 to 10.7% by 2021. CONCLUSION: The co-regulation agreement could save lives and reduce the risk of premature death in Portugal. Nevertheless, the projected impact on mortality was insufficient to meet international targets.

The perspectives of politicians on tobacco control in Turkey.

Background: Tobacco use is a leading but preventable cause of non-communicable diseases and premature death. The legislature has a key role in setting tobacco control policies. Smoking trends are decreasing thanks to the introduction of effective tobacco control policies in Turkey and these policies may have been shaped by how politicians' interpreted social problems that were prominent during the development and implementation of tobacco regulations. Aim: This paper explores the long-term national relationship between tobacco consumption, tobacco control policies and the associated political discourse in Turkey, considering the varying influences through national leadership on this important public health agenda. This relationship is studied by comparing a time series analysis of tobacco consumption trends with a policy analysis of the minutes of deliberations at the Grand National Assembly of Turkey (GNAT). Methods: This study uses Bayesian time series analysis in order investigate whether the tobacco control policies and related activities influenced the annual per adult cigarette consumption in Turkey. We used a novel method to identify change points in tobacco trends and whether they correspond with key policy changes intended to alter usage after adjusting for the effect of other non-policy related covariates, such as the purchasing power. The policy analysis included an examination of the minutes of deliberations at the GNAT-which is the Turkish parliament and unicameral Turkish legislature-1 year before and 1 year after the break years associated with an increase or decrease in tobacco consumption. Results and recommendations: Tobacco consumption increased with the encouragement of tobacco production and the entrance of multinational companies in the country in 1976 and 1993, respectively. The National Tobacco Law of 1996 and comprehensive amendments in 2008, including smoke-free public places and tax increases, appear to have helped reduce tobacco consumption in Turkey. The focus of Parliamentary discussions throughout this period changed, becoming less supportive of tobacco over time. However, throughout the period there remained discussions focussing on concerns around the implications for the economy and the privatization agenda, national agriculture and the welfare of farmers. Effective control appears to require certain political ingredients to be implemented: politicians who are well informed on tobacco control measures and understand the range of issues surrounding the policies (not only those directly health-related); and supportive public health information in the community. Evidence-based public health policy should be introduced to the politicians.

Variation across Romania in the health impact of increasing tobacco taxation.

Background: Tobacco is the leading preventable cause of death globally and tobacco taxation is a cost-effective method of reducing tobacco use in countries and increasing revenue. However, without adequate enforcement some argue the risk of increasing illicit trade in cheap tobacco makes taxation ineffective. We explore this by testing sub-national variations in the impact of tobacco tax increases from 2009 to 2011, on seven smoking-related diseases in adults in Romania, to see if regions that are prone to cigarette smuggling due to bordering other countries see less benefit. Method: We use a pragmatic natural experiment study approach to analyse the study period 2009-15. Findings from hospital episodes data relating to smoking-attributable diseases are analysed for six regional subgroups which are compared according to border characteristics with other countries. Results: At a national level smoking-attributable diseases reduced over the study period especially around the tax increase years, with asthma showing the most significant decline. Sub-nationally there was no statistically significant correlation in variations between central regions and those bordering other countries. Conclusion: There is a reassuring decline in hospitalizations for smoking-related diseases associated with the tax increases, and no sub-national association with smuggling risk measured by variation in the size of this effect and regions that border other countries. More comprehensive and progressive tobacco control in Romania should be implemented in line with the WHO Framework Convention for Tobacco Control.

Effects of tobacco control policy on cardiovascular morbidity and mortality in Russia.

Background: According to the Global Adult Tobacco Survey carried out in Russia in 2009, the country had one of the highest smoking prevalence rates in Europe. In response to this health and economic burden, Russia implemented a comprehensive Tobacco Control Law (TCL) in 2013, which has been associated with a 21.5% relative decline in adult smoking prevalence in 2016 compared with 2009. This study tests the impact of the TCL on cardiovascular disease (CVD) related health outcomes, including morbidity and mortality. Method: The study evaluated the TCL as an intervention in a natural experiment during the period 2003-2015. A synthetic control was created as a comparator, using data from countries that did not have a comparable comprehensive tobacco control intervention. Changes in trends in CVD outcomes - hospital discharge rates (HDRs) and standardized death rates (SDRs) - were then compared to test for an impact associated with the TCL. Results: Pre-intervention trends in CVD-related HDRs were similar between Russia and the synthetic control, but became divergent after the TCL with greater benefit observed in Russia. This implies a beneficial impact of the TCL on CVD related morbidity in the Russian population. Whilst SDRs continued to reduce in both Russia and the control, the impact of TCL is less clear. Conclusion: This study provides further evidence to support comprehensive tobacco control in line with the WHO Framework Convention for Tobacco Control (WHO FCTC). Alongside a reduction in tobacco consumption, smoking-related CVD morbidity appears to benefit quite soon after implementation, whilst smoking-related deaths might need a longer post-intervention period to be detectable.

Impact of Austria's 2009 trans fatty acids regulation on all-cause, cardiovascular and coronary heart disease mortality.

Background: Unhealthy diet, especially consumption of trans fatty acids (TFAs), is a known risk factor for cardiovascular disease (CVD), a leading cause of death in Austria. In 2009, Austria introduced a law regulating the content of TFAs in foods. The aim of this study was to assess the impact of the TFA regulation on CVD-related outcomes. Methods: The study evaluated the TFA regulation as an intervention in a natural experiment. Two study periods were assessed: pre-intervention (1995-2009) and post-intervention (2010-14). The study compared the age-standardized death rates per 100 000 population for CVD outcomes with those of a 'synthetic' international comparator population, created from data of OECD countries where TFA regulation has not been implemented, but where the population is otherwise comparable. Results: There was a continuous decrease in CVD-related mortality throughout the study period in both the synthetic international comparator population, as well as in the adult Austrian population, with no significant change in this trend observed as an effect of TFA regulation. Conclusions: Whilst the results are counterintuitive, given the established link between TFA consumption and an increased risk of CVD, there are many possible explanations: high prevalence of tobacco smoking, changes in TFA content in foods due to international guidance as opposed to formal regulation and a beneficial impact of TFA regulation on sub-groups of the population that might not be detected with nationally aggregated data. However, reduction in TFAs should still be considered an important part of risk factor reduction for CVD and other non-communicable diseases.