Improving Information to Enable Effective Tobacco Control Intervention and Measure Progress Over Time: The Cambodia Country Experience.

Tobacco is a leading cause of noncommunicable diseases (NCDs) which kill about 41 million people each year. Of these, 15 million die prematurely between the ages of 30 and 69 years, most of which occur in low- and middle-income countries (LMICs). The adoption of the Sustainable Development Goals and their targets under the 2030 Agenda for Sustainable Development provides a new impetus for countries to accelerate tobacco control efforts as they specifically call for strengthening implementation of the World Health Organization (WHO) Framework Convention on Tobacco Control and striving to achieve a one-third reduction in premature deaths from NCDs. While NCD prevention and control is a priority in the national strategic plans and policies for health in most countries in the Western Pacific Region, few have formally adopted a national target for reducing tobacco use. Article 20 of the WHO FCTC calls on all countries to improve tobacco surveillance to enable monitoring and evaluation of tobacco control efforts. The increase in timely and standardized comparable data presents new opportunities to set scientifically valid and achievable national indicators and targets for development and implementation of strong tobacco control measures. Cambodia is yet to establish national targets and full implementation of legislative measures. However, with strong tobacco surveillance mechanism in place, it can provide the country experience for a LMIC that has developed its own capacity to conduct periodic monitoring and surveillance of tobacco use and for using national data to advocate successfully for stronger tobacco control policies.

Maternal use of cigarettes, pipes, and smokeless tobacco associated with higher infant mortality rates in Cambodia.

In the Western Pacific Region, rural women use loose tobacco in betel quid chewing and pipe smoking. We examined the relation between maternal use of tobacco and infant mortality (IM) in a national sample of 24 296 birth outcomes in adult women (n = 6013) in Cambodia. We found that (1) age-adjusted odds of IM were higher for maternal use of any tobacco (odds ratio [OR] = 1.69; 95% confidence interval [CI] = 1.27-2.26); (2) age-adjusted odds of IM were higher for cigarette use (OR = 2.54; 95% CI = 1.54- 4.1), use of pipes (OR = 3.09; [95% CI = 1.86-5.11]), and betel quid chewing (OR = 1.55; 95% CI = 1.10-2.17); and (3) these associations remained after multivariable adjustment for environmental tobacco smoke, malnutrition, ethnicity, religion, marital status, education, income, occupation, and urban/rural dwelling. In addition to finding the established association with cigarettes, we also found that maternal use of smokeless tobacco and pipes was associated with higher rates of infant death in Cambodia.

Patterns of maternal tobacco use among Cambodian women: findings from a nationwide sample.

Although current trends indicate that the rate of cigarette smoking tends to be low among women in the Western Pacific Region (<10%), recent epidemiologic data from South Asia (India, Bangladesh) and Southeast Asia (Cambodia, Vietnam, Indonesia, Malaysia) identify that a large proportion of women of reproductive age and older chew tobacco--often as part of a betel quid mixture that includes other potentially harmful ingredients (eg, areca nut). Our findings from currently pregnant women identified during a nationwide survey of adult tobacco use in Cambodia indicate that 13.0% (95% confidence interval [CI] = 8% to 17%) were current users of smoked or smokeless (in the form of a betel quid) tobacco. Most pregnant women who used tobacco indicated that their habit was either initiated (29.1%; 95% CI = 16.3-46.3) or increased (33.7%; 95% CI = 18.3-53.5) during pregnancy. Pregnancy-related symptoms such as morning sickness were reported as the reason for more than half (54.9%; 95% CI = 34.8-73.4) of the currently pregnant users to have started a tobacco habit during their lifetime. Among those pregnant women who did not use tobacco, we found strong associations (odds ratios from 2 to 14) with beliefs about the harmful effects of tobacco on adult health, faith-based beliefs in addictive substances, and beliefs that influential members of the community, health professionals, and children should not use tobacco. Our findings indicate that tobacco cessation and prevention programs in Cambodia should specifically target pregnant and reproductive-age women.

Patterns of alcohol and tobacco use in Cambodia.

Few studies have considered whether the habitual use of tobacco in Southeast Asia is part of an established pattern of addiction that includes regular alcohol use. As part of a national survey of adult tobacco use in Cambodia (n = 13 988), we found that men who smoked were 2 times more likely to have drank alcohol in the past week (odds ratio = 2.53, 95% confidence interval = 2.10-3.03). By age 18 to 25 years, 47% of male smokers drank alcohol, and this pattern of alcohol and tobacco use increased to >55% through the fifth decade. Women using smokeless tobacco with betel quid were more likely to be alcohol drinkers (odds ratio = 1.49, 95% confidence interval = 1.12-1.98). Past week's drinking declined by late middle age and was associated with lower education and being currently married; the behavior was lower in some ethnic groups (ie, Cham). Our findings indicate an important association between alcohol and tobacco use, and raise the possibility that reducing alcohol consumption can be an important component of tobacco control.

Adult tobacco cessation in Cambodia: II. Determinants of intent to quit.

Identifying determinants of intent to quit may aid the design of antitobacco programs and promote effective tobacco control policies. In a nationwide survey in Cambodia, two thirds of tobacco smokers and 45% of female smokeless tobacco users planned to stop in the future. Multivariate determinants of intent in 2279 male smokers were age <37 years, age at initiation ≥ 18 years, Cham versus Khmer ethnicity (odds ratio [OR] = 6.93; 95% confidence interval[CI] = 1.38-34.89), longer education, and professional occupation. In 1188 female smokeless tobacco users, age <25 years, age at initiation ≥ 18 years, and tuberculosis (OR = 3.26; 95% CI = 1.61-6.61) were associated with intent. In female smokers (n = 321), age 18 to 25 years at initiation was associated with intent. In male smokers and female smokeless tobacco users, perceived physical advantages of tobacco were inversely associated with intent. These findings underscore the importance of policies and interventions to delay initiation and promote cessation in young people and counteract perceived physical benefits.

Adult tobacco cessation in Cambodia: I. Determinants of quitting tobacco use.

This study determined factors associated with quitting tobacco in Cambodia, a country with a high prevalence of men who smoke and women who use smokeless tobacco. As part of a nationwide survey, face-to-face interviews were conducted with 5145 current and 447 former tobacco users who had quit for ≥ 2 years. Determinants of quitting in multivariate analyses were age >48 years, age at initiation >25 years, ≥ 7 years of education, income ≥ 1 US dollar per day, professional (odds ratio [OR] = 2.52; 95% confidence interval [CI] = 1.27-5.01) or labor (OR = 1.98, 95% CI = 1.10-3.56) occupations, and heart disease (OR = 1.94; 95% CI = 1.10, 3.42). Smokeless tobacco users were 10-fold less likely to quit (OR = 0.10; 95% = CI 0.05-0.20) than smokers. In conclusion, tobacco cessation among Cambodians was lower than in nations with decades of comprehensive tobacco control policies. Tobacco cessation programs and policies should include all forms of tobacco and target young to middle-aged users before onset of disease and premature death.