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.

Comparing cancer and cardiovascular disease trends in 20 middle- or high-income countries 2000-19: A pointer to national trajectories towards achieving Sustainable Development goal target 3.4.

With the 2030 Sustainable Development Goals (SDG) target of a one-third reduction in noncommunicable diseases (NCDs) less than a decade away, it is timely to assess national progress in reducing premature deaths from the two leading causes of mortality worldwide. We examine trends in the probability of dying ages 30-70 from cardiovascular disease (CVD) and cancer 2000-19 in 10 middle-income (MICs) and 10 high-income (HICs) countries with high quality data. We then predict whether the SDG target will be met in each country for CVD, cancer and for the four main NCDs combined. Downward trends were more evident in HICs relative to the MICs, and for CVD relative to cancer. CVD and cancer declines ranged from 30-60% and 20-30% in HICs over the 20-year period, but progress was less uniform among the MICs. Premature deaths from cancer exceeded CVD in nine of the 10 HICs by 2000 and in all 10 by 2019; in contrast, CVD mortality exceeded cancer in all 10 MICs in 2000 and remained the leading cause in eight countries by 2019. Two of the 10 MICs (Colombia and Kazakhstan) and seven of the HICs (Australia, Chile, Italy, New Zealand, Norway, Slovakia, and the U.K.) are predicted to meet the SDG NCDs target. Whether countries are on course to meet the target by 2030 reflects changing risk factor profiles and the extent to which effective preventative and medical care interventions have been implemented. In addition, lessons can be learned given people living with NCDs are more susceptible to severe COVID-19 illness and death.

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.

Interact, engage or partner? Working with the private sector for the prevention and control of noncommunicable diseases.

Noncommunicable diseases (NCDs), including cardiovascular diseases (CVDs), cancers, chronic respiratory diseases and diabetes, account for 72% of all global deaths, with 78% of all NCDs taking place in low- and middle-income countries. Among these four main groups of NCDs, CVDs are taking the highest death toll at 17.9 million or 44% of all NCD mortality. This paper suggests that the complex interplay of NCD risk factors and their underlying social and commercial determinants requires active cooperation with the private sector to bring about policy change, pool resources and generate innovative solutions by capitalizing on each partner's strengths. However, such partnerships can only be successful if safeguards are in place to define the rules of engagement, align incentives to achieve shared public health objectives and manage potential conflicts of interest.

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.

A systematic review of associations between non-communicable diseases and socioeconomic status within low- and lower-middle-income countries.

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of death globally. Eighty-two percent of premature NCD deaths occur within low- and lower middle-income countries (LLMICs). Research to date, largely drawn from high-income countries, suggests that disadvantaged and marginalized groups have a higher NCD burden, but there has been a dearth of research studying this relationship within LLMICs. The purpose of this systematic review is to map the literature on evidence from LLMICs on the socio-economic status (SES) gradient of four particular NCDs: cardiovascular disease, cancer, diabetes, and chronic respiratory diseases. METHODS: We conducted a comprehensive literature search for primary research published between 1 January 1990 and 27 April 2015 using six bibliographic databases and web resources. We included studies that reported SES and morbidity or mortality from cardiovascular disease, cancer, diabetes and chronic respiratory diseases within LLMICs. RESULTS: Fifty-seven studies from 17 LLMICs met our inclusion criteria. Fourteen of the 18 papers that reported significant associations between cancer and SES suggested that low SES groups had the highest cancer risk. Eleven of 15 papers reporting significant relationships between CVD and SES suggested that low SES groups have higher risk. In contrast, seven of 12 papers reporting significant findings related to diabetes found that higher SES groups had higher diabetes risk. We identified just three studies on the relationship between chronic respiratory diseases and SES; none of them reported significant findings. CONCLUSIONS: Only 17 of the 84 LLMICs were represented, highlighting the need for more research on NCDs within these countries. The majority of studies were medium to high quality cross-sectional studies. When we restricted our analyses to high quality studies only, for both cancer and cardiovascular disease more than half of studies found a significantly higher risk for those of lower SES. The opposite was true for diabetes, whilst there was a paucity of high quality research on chronic respiratory disease. Development programmes must consider health alongside other aims and NCD prevention interventions must target all members of the population. SYSTEMATIC REVIEW REGISTRATION NUMBER: Prospero: CRD42015020169.

Evaluation of research on interventions aligned to WHO 'Best Buys' for NCDs in low-income and lower-middle-income countries: a systematic review from 1990 to 2015.

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of death and disability worldwide, with low-income and middle-income countries experiencing a disproportionately high burden. Since 2010 WHO has promoted 24 highly cost-effective interventions for NCDs, dubbed 'best buys'. It is unclear whether these interventions have been evaluated in low-income and lower-middle-income countries (LLMICs). AIM: To systematically review research on interventions aligned to WHO 'best buys' for NCDs in LLMICs. METHODS: We searched 13 major databases and included papers conducted in the 83 World Bank-defined LLMICs, published between 1 January 1990 and 5 February 2015. Two reviewers independently screened papers and assessed risk of bias. We adopted a narrative approach to data synthesis. The primary outcomes were NCD-related mortality and morbidity, and risk factor prevalence. RESULTS: We identified 2672 records, of which 36 were included (608 940 participants). No studies on 'best buys' were found in 89% of LLMICs. Nineteen of the 36 studies reported on the effectiveness of tobacco-related 'best buys', presenting good evidence for group interventions in reducing tobacco use but weaker evidence for interventions targeting individuals. There were fewer studies on smoking bans, warning labels and mass media campaigns, and no studies on taxes or marketing restrictions. There was supportive evidence that cervical screening and hepatitis B immunisation prevent cancer in LLMICs. A single randomised controlled trial supported polypharmacy for cardiovascular disease. Fourteen of the 'best buy' interventions did not have any good evidence for effectiveness in LLMICs. CONCLUSIONS: We found studies on only 11 of the 24 interventions aligned with the WHO 'best buys' from LLMIC settings. Most LLMICs have not conducted research on these interventions in their populations. LLMICs should take action to implement and evaluate 'best buys' in their national context, based on national priorities, and starting with interventions with the strongest evidence base.

The impact of poverty reduction and development interventions on non-communicable diseases and their behavioural risk factors in low and lower-middle income countries: A systematic review.

INTRODUCTION: Non-communicable diseases (NCDs) disproportionately affect low- and lower-middle income countries (LLMICs) where 80% of global NCD related deaths occur. LLMICs are the primary focus of interventions to address development and poverty indicators. We aimed to synthesise the evidence of these interventions' impact on the four primary NCDs (cardiovascular disease, diabetes, chronic respiratory disease and cancer) and their common behavioural risk factors (unhealthy diets, physical inactivity, tobacco and alcohol use). METHODS: We systematically searched four online databases (Medline, Embase, Web of Science and Global Health) for primary research conducted in LLMICS, published between January 1st 1990 and February 15th 2016. Studies involved development or poverty interventions which reported on outcomes relating to NCDs. We extracted summary level data on study design, population, health outcomes and potential confounders. RESULTS: From 6383 search results, 29 studies from 24 LLMICs published between 1999 and 2015 met our inclusion criteria. The quality of included studies was limited and heterogeneity of outcome measures required narrative synthesis. One study measured impact on NCD prevalence, one physical activity and 27 dietary components. The majority of papers (23), involved agricultural interventions. Primary outcome measures tended to focus on undernutrition. Intensive agricultural interventions were associated with improved calorie, vitamin, fruit and vegetable intake. However, positive impacts were reliant on participant's land ownership, infection status and limited in generalisability. Just three studies measured adult obesity; two indicated increased income and consequential food affordability had the potential to increase obesity. Overall, there was poor alignment between included studies outcome measures and the key policy options and objectives of the Global Action Plan on NCDs. CONCLUSIONS: Though many interventions addressing poverty and development have great potential to impact on NCD prevalence and risk, most fail to measure or report these outcomes. Current evidence is limited to behavioural risk factors, namely diet and suggests a positive impact of agricultural-based food security programmes on dietary indicators. However, studies investigating the impact of improved income on obesity tend to show an increased risk. Embedding NCD impact evaluation into development programmes is crucial in the context of the Sustainable Development Goals and the rapid epidemiological transitions facing LLMICs.

Socioeconomic status and non-communicable disease behavioural risk factors in low-income and lower-middle-income countries: a systematic review.

BACKGROUND: Non-communicable diseases are the leading global cause of death and disproportionately afflict those living in low-income and lower-middle-income countries (LLMICs). The association between socioeconomic status and non-communicable disease behavioural risk factors is well established in high-income countries, but it is not clear how behavioural risk factors are distributed within LLMICs. We aimed to systematically review evidence on the association between socioeconomic status and harmful use of alcohol, tobacco use, unhealthy diets, and physical inactivity within LLMICs. METHODS: We searched 13 electronic databases, including Embase and MEDLINE, grey literature, and reference lists for primary research published between Jan 1, 1990, and June 30, 2015. We included studies from LLMICs presenting data on multiple measures of socioeconomic status and tobacco use, alcohol use, diet, and physical activity. No age or language restrictions were applied. We excluded studies that did not allow comparison between more or less advantaged groups. We used a piloted version of the Cochrane Effective Practice and Organisation of Care Group data collection checklist to extract relevant data at the household and individual level from the included full text studies including study type, methods, outcomes, and results. Due to high heterogeneity, we used a narrative approach for data synthesis. We used descriptive statistics to assess whether the prevalence of each risk factor varied significantly between members of different socioeconomic groups. The study protocol is registered with PROSPERO, number CRD42015026604. FINDINGS: After reviewing 4242 records, 75 studies met our inclusion criteria, representing 2 135 314 individuals older than 10 years from 39 LLMICs. Low socioeconomic groups were found to have a significantly higher prevalence of tobacco and alcohol use than did high socioeconomic groups. These groups also consumed less fruit, vegetables, fish, and fibre than those of high socioeconomic status. High socioeconomic groups were found to be less physically active and consume more fats, salt, and processed food than individuals of low socioeconomic status. While the included studies presented clear patterns for tobacco use and physical activity, heterogeneity between dietary outcome measures and a paucity of evidence around harmful alcohol use limit the certainty of these findings. INTERPRETATION: Despite significant heterogeneity in exposure and outcome measures, clear evidence shows that the burden of behavioural risk factors is affected by socioeconomic position within LLMICs. Governments seeking to meet Sustainable Development Goal (SDG) 3.4-reducing premature non-communicable disease mortality by a third by 2030-should leverage their development budgets to address the poverty-health nexus in these settings. Our findings also have significance for health workers serving these populations and policy makers tasked with preventing and controlling the rise of non-communicable diseases. FUNDING: WHO.