A decade of tobacco control efforts: Implications for tobacco smoking prevalence in Eastern Mediterranean countries.

BACKGROUND AND OBJECTIVES: This study aimed to assess the association between the 10-year implementation of tobacco control policies, cigarette affordability index and changes in tobacco smoking prevalence across Eastern Mediterranean (EMR) countries. MATERIALS AND METHODS: An ecologic study was conducted using EMR countries as the analytical unit. Data from three sources were utilized: the MPOWER scale to measure tobacco control policy implementation (2010-2020), the tobacco affordability index (expressed as a percentage of GDP per capita required to purchase 2000 cigarettes, from 2010 to 2020), and national tobacco smoking prevalence data for EMR countries (2010-2023). Linear Fixed-effect regression was employed to investigate associations between changes in MPOWER scores, the cigarette affordability index, and alterations in tobacco prevalence over a decade. RESULTS: Statistically significant inverse associations were observed between changes in MPOWER scores and tobacco smoking prevalence among both men and women in EMR countries (P-value<0.05). Each unit increase in MPOWER score corresponded to a 0.26% reduction in tobacco prevalence among men and a 0.12% reduction among women. The regression model revealed that each unit increase in the cigarette affordability index was linked to a 0.9% decrease in tobacco smoking prevalence across EMR countries (P-value<0.05). Furthermore, even after adjusting for multiple confounders, significant inverse associations were noted between tobacco monitoring (ß = -0.41), health warning (ß = -0.45), and changes in tobacco smoking prevalence (P-value<0.05). CONCLUSION: This study underscored the effectiveness of enhancing the implementation of tobacco control policies and increasing the cigarette affordability index as preventive measures to reduce tobacco smoking prevalence in EMR countries over the past decade.

National and Regional Fraction of Cancer Incidence and Death Attributable to Current Tobacco and Water-Pipe Smoking in the Eastern Mediterranean Countries in 2020.

INTRODUCTION: We aimed to calculate the Population Attributable Fraction (PAF) of cancers due to tobacco use in the Eastern Mediterranean Region (EMRO), where water-pipe smoking is prevalent but its effect was not considered in previous studies. AIMS AND METHODS: We applied Levin's formula to estimate PAFs of cancers due to tobacco use (defined as all type tobacco including both cigarette and water-pipe). We also calculated PAF of water-pipe smoking separately. Exposure prevalence data were retrieved from representative national and subnational surveys. Data on cancer incidence and death were also and cancer cases were obtained GLOBOCAN 2020. We also obtained associated relative risks from published meta-analyses. RESULTS: Of the total 715 658 incident adult cancer cases that were reported in 2020 in EMRO, 14.6% (n = 104 800) was attributable to tobacco smoking (26.9% [n = 92 753]) in men versus 3.3% (n = 12 048) in women. Further, 1.0% of incident adult cancers were attributable to current water-pipe use (n = 6825) (1.7% [n = 5568]) in men versus 0.4% (n = 1257 in women). CONCLUSIONS: PAFs of cancers due to tobacco smoking in EMRO were higher in our study than previous reports. This could be due to the neglected role of water-pipe in previous studies that is a common tobacco smoking method in EMRO. The proportion of cancers attributable to water-pipe smoking in EMRO might be underestimated due to lack of research on the risk of cancers associated with water-pipe smoking and also less developed cancer registries in EMRO. IMPLICATIONS: In this study, we found higher PAFs for cancers due to tobacco smoking in the Eastern Mediterranean (EMR) region than previous reports. This difference could be due to ignoring the role of water-pipe smoking in previous studies. In 2020, 1% of incident cancers and 1.3% of cancer-related deaths in EMRO were attributable to water-pipe smoking. We also found a big difference in PAFs of cancers due to tobacco and water-pipe smoking across EMRO countries, with Tunisia, Lebanon, and Jordan having the highest, and Djibouti, Sudan, and Somalia having the lowest proportions of cancers attributable to tobacco and water-pipe smoking.

Clinical Breast Cancer Registry of IR. Iran (CBCR-IR): Study Protocol and First Results.

BACKGROUND: Breast cancer (BC), as a significant global health problem, is the most common cancer in women. Despite the importance of clinical cancer registries in improving the quality of cancer care and cancer research, there are few reports on them from low- and middle-income countries. We established a multicenter clinical breast cancer registry in Iran (CBCR-IR) to collect data on BC cases, the pattern of care, and the quality-of-care indicators in different hospitals across the country. METHODS: We established a clinical cancer registry in 12 provinces of Iran. We defined the organizational structure, developed minimal data sets and data dictionaries, verified data sources and registration processes, and developed the necessary registry software. During this registry, we studied the clinical characteristics and outcomes of patients with cancer who were admitted from 2014 onwards. RESULTS: We registered 13086 BC cases (7874 eligible cases) between 1.1.2014 and 1.1.2022. Core needle biopsy from the tumor (61.25%) and diagnostic mammography (68.78%) were the two most commonly used diagnostic methods. Stage distribution was 2.03% carcinoma in situ, 12% stage I, 44.65% stage II, 21.32% stage III, and 4.61% stage IV; stage information was missing in 1532 patients (19.46%). Surgery (95.01%) and chemotherapy (79.65%) were the most common treatments for all patients. CONCLUSION: The information provided by this registry can be used to evaluate and improve the quality of care for BC patients. It will be scaled up to the national level as an important resource for measuring quality of care and conducting clinical cancer research in Iran.

A comparative study of tobacco control scale score in the Eastern Mediterranean Region countries.

Background: The tobacco control scale (TCS) score is used widely in European countries to evaluate the adoption of anti-tobacco policies by countries, however, data on the adoption of tobacco control programmes in the Eastern Mediterranean Region (EMR) are limited to a 2009 survey. Aim: To compare the TCS score for measuring national tobacco control programmes in the EMR countries in 2009 and 2021. Methods: This cross-sectional survey compared data from 21 EMR countries on 6 major indicators, including the price of cigarettes, tobacco smoke-free public places, national budget for tobacco control activities, ban on tobacco advertising, health warning labels on tobacco packets, and support for treatment of tobacco dependence. The TCS scores at the country level in 2009 were extracted from a previous study. We then calculated the TCS score in 2021 for the same countries using the WHO report on the global tobacco epidemic 2021 and the World Bank data for 2020. Results: The average TCS score (standard deviation) for EMR countries increased from 29.7 (16.8) in 2009 to 40.7 (17.3) in 2021. The highest TCS score (83.0) was reported in Islamic Republic of Iran, followed by Yemen (72.8) and Lebanon (62.0). Five countries (Djibouti, Syrian Arab Republic, Tunisia, Bahrain, and Oman) scored less than 30. Health warning labels, smoke-free public places, and tobacco control budgets as a percentage of Gross Domestic Product per capita had all increased, but tobacco prices and cessation treatments did not improve over the past decade. Conclusion: Tobacco control policies have been implemented and improved in most EMR countries, but there is room for further improvement. Tobacco pricing and taxation, national tobacco control program budgets, and cessation treatments require more attention.

Trends of in-hospital and ICU mortality in COVID-19 patients over the fourth and fifth COVID-19 surges in Iran: a retrospective cohort study from Iran.

OBJECTIVE: The current study aimed to investigate the temporal trend of in-hospital and intensive care unit (ICU) mortality of coronavirus disease 2019 (COVID-19) patients over 6 months in the spring and summer of 2021 in Iran. DESIGN: We performed an observational retrospective cohort study. SETTING: Qazvin Province- Iran during 6 month from April to September 2021. PARTICIPANTS: All 14355 patients who were hospitalized with confirmed COVID-19 in hospitals of Qazvin Province. INTERVENTION: No intervention. MAIN OUTCOME MEASURES: The trends of overall in-hospital mortality and ICU mortality were the main outcome of interest. We obtained crude and adjusted in-hospital and ICU mortality rates for each month of admission and over surge and lull periods of the disease. RESULTS: The overall in-hospital mortality, early mortality and ICU mortality were 8.8%, 3.2% and 67.6%, respectively. The trend for overall mortality was almost plateau ranging from 6.5% in July to 10.7% in April. The lowest ICU mortality was 60.0% observed in April, whereas it reached a peak in August (ICU mortality = 75.7%). Admission on surge days of COVID-19 was associated with an increased risk of overall mortality (Odds ratio = 1.3, 95% confidence interval = 1.1, 1.5). The comparison of surge and lull status showed that the odds of ICU mortality in the surge of COVID-19 was 1.7 higher than in the lull period (P-value < 0.001). CONCLUSIONS: We found that the risk of both overall in-hospital and ICU mortality increased over the surge period and fourth and fifth waves of severe acute respiratory syndrome coronavirus 2 infection in Iran. The lack of hospital resources and particularly ICU capacities to respond to the crisis during the surge period is assumed to be the main culprit.

Decomposition of socioeconomic inequality in COVID-19 mortality in Iran: A retrospective cohort study.

This study aimed to investigate the relationship between socioeconomic status and COVID-19 mortality in Iran. We performed a retrospective cohort study on data from the hospitalised COVID-19 patients in Qazvin. We collected data on education, self-reported socioeconomic status, and location of residence as a proxy for socioeconomic status (SES). We applied the Blinder-Oaxaca decomposition approach to assess the role of socioeconomic inequality in COVID-19 mortality and determine the main contributors to the observed inequality. Overall, 941 patients (48.96%) had low SES, while only 24.87% (n = 478) were classified in the high SES category. The mortality rate was significantly higher in the low SES group, and we spotted a 17.13% gap in COVID-19 mortality between the high and low SES patients (p < 0.001). Age was the main contributor to the observed inequality, responsible for 6.91% of the gap (p < 0.001). Having co-morbidities (1.53%) and longer length of stay (LOS) in hospitals (0.95%) in the low SES group were other main determinants of the inequality in COVID-19 mortality (p < 0.05). In the unexplained part of our model, the effect of increased age (10.61%) and a positive RT-PCR test result (3.43%) were more substantial in the low SES group compared to the high SES patients (p < 0.05). The low SES people had an increased risk of getting COVID-19, and the disease has been more severe and fatal among them. Increased age, co-morbidities, and LOS were identified as the main drivers of this inequality.

COVID19 Prevention & Care; A Cancer Specific Guideline.

On March 11th 2020, the coronavirus outbreak was declared a pandemic by the WHO. One of the groups that is considered high risk in this pandemic are cancer patients as they are treated with a variety of immune system suppressor treatment modalities and this puts them in a great risk for infectious disease (including COVID-19). Therefore, cancer patients require higher level measures for preventing and treating infectious diseases. furthermore, cancer patients may bear additional risk due to the restriction of access to the routine diagnostic and therapeutic services during such epidemic. Since most of the attention of health systems is towards patients affected with COVID-19, the need for structured and unified approaches to COVID-19 prevention and care specific to cancer patients and cancer centers is felt more than ever. This article provides the recommendations and possible actions that should be considered by patients, their caregivers and families, physician, nurses, managers and staff of medical centers involved in cancer diagnosis and treatment. We pursued two major goals in our recommendations: first, limiting the exposure of cancer patients to medical environments and second, modifying the treatment modalities in a manner that reduces the probability of myelosuppression such as delaying elective diagnostic and therapeutic services, shortening the treatment course, or prolonging the interval between treatment courses.

Factors affecting professional delay in diagnosis and treatment of oral cancer in Iran.

BACKGROUND: Oral cancer is the most common malignant tumor among head and neck cancers. Delay in diagnosis affects the treatment and prognosis of oral cancer. We measured the professional delay in the diagnosis and its attributes in the Cancer Institute of Iran, the largest referral center for oral cancer patients in the country.  METHODS: We interviewed oral cancer patients to measure the delay and used case-control approach to study association of various prognostic factors with professional delay and tumor stage. RESULT: Out of 206 patients, 71.4% were diagnosed at the advanced stage. The median of the patient, professional and total delays were 45, 86 and 140 day, receptively. In the univariate model, prescription of medicines like analgesics (OR = 5.3, 95% CI 2.2-12.9) and history of dental procedure (OR=6.8, 95% CI 1.7-26.9) were associated with higher risk of delay compared to patient who were biopsied from the beginning. History of loose teeth increased risk of delay 4 times (OR = 4.0, 95% CI 1.6-9.8). Patients with primary education had 70% lower risk of delay compared to the illiterate patients (OR = 0.3, 95% CI 0.1-0.7) and the risk was lower among patients who had diploma (OR = 0.04, 95% CI 0-0.7) and college education (OR = 0.1, 95% CI 0-0.4). The delayed patients were diagnosed in more advanced stage compared to the patients without delay (OR = 2.1, 95% CI 1.0-4.4). CONCLUSION: Development of a national guideline for follow-up of oral lesions, training and awareness of health care professionals about oral cancer diagnosis may decrease the delay and improve the oral cancer outcome in Iran.