Towards health with justice: making the tobacco industry accountable through administrative liability.

For many decades, the transnational tobacco industry has evaded the consequences of harming people and the planet. Despite selling a deadly product, it has continued to remain one of the most profitable industries in the world, now venturing into 'wellness and pharmaceutical' businesses as part of its diversification strategy. Meanwhile, efforts to make the tobacco industry pay through court systems have not progressed due to the inherent challenges within the judicial systems in most countries. This paper explores mechanisms for ensuring accountability through administrative liability, including the use of compensation mechanisms and adjudicatory bodies. Such mechanisms operationalise vital principles and practices derived from international law, such as the imposition of effective, proportionate, and dissuasive non-criminal sanctions, victims' right to compensation, and 'polluter pays' principles. Measures such as taxation, surcharges, penalties, financial guarantees or insurance, along with the establishment of adjudicatory bodies and trust funds, are discussed. In order to hold the tobacco industry to account for the wide range of harms caused by its products and its misconduct; policies on 'liability' must clearly articulate how the industry will compensate for past and future harms in a manner that deters it from causing further damage.

Tactics of the tobacco industry in an Arab nation: a review of tobacco documents in Oman.

BACKGROUND: Few studies have investigated tobacco industry interference in the tobacco control policies of Arab nations. This paper explores the tactics used by the industry to subvert tobacco control policies in Oman and offers lessons on how to prevent such interference in the future. METHODS: We searched the Truth Tobacco Industry Documents Archive using the word 'Oman', names of government institutions, policymakers and local tobacco distributors. Extracted data were noted chronologically by key elements of tobacco control measures. Gulf Cooperation Council (GCC) Health Ministers' Council resolutions on tobacco control were also reviewed. RESULTS: Out of 1020 tobacco documents located, 327 were closely related to policy interference. Documents revealed that the industry met key government officials, offered in-kind services, used local diplomatic missions to influence Omani policymakers, opposed smoking bans, delayed regulations to lower tar and nicotine content of cigarettes, and to require effective health warnings, circumvented a tobacco advertising, promotion and sponsorship ban and provided voluntary codes as an alternative to effective regulations. Additionally, industry representatives lobbied individual countries in the GCC to veto tax increments and defeat consensus on agreed resolutions of the Health Ministers' Council. CONCLUSION: The tobacco industry interfered in all key public health policies aimed to reduce tobacco use in Oman. There is an urgent need for the Omani government to enforce the Civil Code of Conduct and develop guidelines for all policymakers through implementing Article 5.3 of the WHO Framework Convention on Tobacco Control to curb the tobacco epidemic.

Fly Ash-Based Geopolymer Composites: A Review of the Compressive Strength and Microstructure Analysis.

Geopolymer (GP) concrete is a novel construction material that can be used in place of traditional Portland cement (PC) concrete to reduce greenhouse gas emissions and effectively manage industrial waste. Fly ash (FA) has long been utilized as a key constituent in GPs, and GP technology provides an environmentally benign alternative to FA utilization. As a result, a thorough examination of GP concrete manufactured using FA as a precursor (FA-GP concrete) and employed as a replacement for conventional concrete has become crucial. According to the findings of current investigations, FA-GP concrete has equal or superior mechanical and physical characteristics compared to PC concrete. This article reviews the clean production, mix design, compressive strength (CS), and microstructure (Ms) analyses of the FA-GP concrete to collect and publish the most recent information and data on FA-GP concrete. In addition, this paper shall attempt to develop a comprehensive database based on the previous research study that expounds on the impact of substantial aspects such as physio-chemical characteristics of precursors, mixes, curing, additives, and chemical activation on the CS of FA-GP concrete. The purpose of this work is to give viewers a greater knowledge of the consequences and uses of using FA as a precursor to making effective GP concrete.

The introduction of tobacco excise taxation in the Gulf Cooperation Council Countries: a step in the right direction of advancing public health.

BACKGROUND: The Gulf Cooperation Council (GCC) countries relied, until recently, solely on import duties for tobacco products. The agreement for the introduction of an excise and value added tax (VAT) in 2016 and 2017, respectively, in most GCC countries, was a major breakthrough for public health. There is, however, ample room for improvement. METHODS: The study examines the outcomes of tax reforms, for both public health and public finances, based on the World Health Organization (WHO) recommendations and best practices worldwide. Tax simulations were performed using the WHO TaXSiM model. The study is based on data from Saudi Arabia, the only GCC country for which sufficient data existed. RESULTS: We recommend a stepwise tax reform, which involves increasing the current ad valorem excise tax rate, phasing out import duties keeping total tax share constant and introducing a minimum excise, and finally switching to a revenue-neutral specific excise. Specific excises must be adjusted for inflation and income increases. If implemented, cigarette tax reform simulations show that the recommended reforms would lead to a higher than 50% increase in cigarette prices, 16% reduction in cigarette sales and almost 50% increase in total cigarette tax revenue. A significant number of cigarette-related deaths would be averted. CONCLUSIONS: The recommended tax reforms are expected to lead to significant improvements in both public health and tobacco tax revenues. Our results provide useful insights that are of relevance to the whole GGC region. The effectiveness of the reforms, however, requires a strong tax and customs administration, including the establishment of a good database to monitor and advance public health.

Clinical Profile of Stroke Patients Presenting to the Emergency Department of a Major Stroke Centre in Oman.

Objectives: Stroke is a significant public health problem and one of the most important preventable non-communicable diseases. Preventive stroke programmes with a better focus on increasing awareness among those who are currently at risk are yet to be properly established in Oman. This study was conducted to describe the characteristics of stroke patients presenting to a tertiary care hospital in Oman. Methods: This cross-sectional hospital-based study included 193 stroke cases which were prospectively recruited from the Emergency Department of Khoula Hospital, Muscat, Oman. Data were collected from November 2017 to April 2018. Results: The total number of patients was 193 with 82.9% of strokes being ischaemic strokes. Of this, 58% were male. The mean age of stroke patients was 61.05 years. Risk factors included hypertension (72.5%) and diabetes mellitus (54.4%). Dyslipidaemia, atrial fibrillation and ischaemic heart diseases were not particularly prevalent in the studied population and 24.4% of ischaemic strokes had large artery atherosclerosis while 21.9% had small vessel occlusion. Significantly more patients had lower Glasgow Coma Scale scores, required intensive care unit admission and experienced in-hospital deaths due to haemorrhagic stroke compared to ischaemic stroke. Conclusion: This study provides essential data regarding stroke characteristics specific to Oman's population. Most of the information obtained appears to be in-line with what has been described internationally and, hence, preventive strategies similar to those indicated in extant literature can be implemented. This information can be utilised by health administrators in planning resource allocation. Further research is needed to explore rehabilitation aspects and long-term outcomes.

Development and Validation of a Risk Score for Diabetes Screening in Oman.

OBJECTIVES: We sought to develop and validate a diabetic risk score model as a non-invasive and self-administered screening tool to be used in the general Omani population. METHODS: The 2008 World Health Survey (WHS) data from Oman (n = 2720) was used to develop the risk score model. Multivariable logistic regression with the backward stepwise method was implemented to obtain risk factors regression coefficients for sex, age, educational attainment, marital status, place of residence, hypertension, body mass index (BMI), waist circumference, tobacco use, daily fruit and vegetable intake, and weekly physical activity. The model coefficients were multiplied by a factor of five to allocate each variable category a risk score. The total score was calculated as the sum of these individual scores. The score was validated using another Omani cohort (Sur Survey 2006 dataset, n = 1355) by calculating the area under the receiver-operating characteristic (ROC) curve (AUC), and optimal score sensitivity and specificity were determined. RESULTS: A robust diabetes risk score model was produced composed of eight variables (age, sex, education level, marital status, place of residence, hypertension, smoking status, and BMI) with an optimal cutoff point of ≥ 15 to classify persons with possible prevalent type 2 diabetes mellitus (T2DM). At this cutoff point, the model had a sensitivity of 71.1%, specificity of 74.4%, and AUC of 0.80 (95% confidence interval (CI): 0.78-0.82), when internally validated (in the WHS 2008 cohort). When the model was externally validated (using the Sur 2006 cohort), the optimal cutoff point for the score was ≥ 13, with a lower sensitivity (54.0%), higher specificity (79.0%), and an AUC of 0.74 (95% CI: 0.70-0.78). In contrast, the test of the old Omani, Kuwaiti, Saudi, and Finnish diabetes risk scores in our study populations showed poor performance of these models among Omanis with poor sensitivity (29% to 63.5%) and reasonable specificity (70% to 80%). CONCLUSIONS: The developed diabetes risk score for screening prevalent T2DM, provides an easy-to-use self-administered tool to identify most individuals at risk of this condition in Oman. The score incorporates eight diabetes-associated risk factors that can also act as a tool to increase people's awareness about the importance of diabetes-related risk factors and provide information for policymakers to establish diabetes prevention programs.

Economic cost of smoking and secondhand smoke exposure in the Gulf Cooperation Council countries.

BACKGROUND: The economic cost of smoking has been determined in many high-income countries as well as at a global level. This paper estimates the economic cost of smoking and secondhand smoke (SHS) exposure in the six Gulf Cooperation Council (GCC) countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates), for which no detailed study exists. METHODS: We used data from the Global Burden of Diseases Study 2016 and the cost-of-illness approach to estimate direct costs (healthcare expenditures) and indirect costs (productivity losses due to morbidity and mortality). Indirect cost was estimated with and without the inclusion of musculoskeletal disorders, using the human capital approach. RESULTS: Total cost of smoking and SHS was estimated to be purchasing power parity (PPP)$ 34.5 billion in 2016, equivalent to 1.04% of the combined gross domestic product (GDP). SHS accounted for 20.4% of total cost. The highest proportion of indirect cost resulted from smoking in men and middle-aged people. The main causes of morbidity cost from smoking and SHS were chronic respiratory diseases and type 2 diabetes mellitus, respectively. Cardiovascular diseases were the main contributor to mortality cost for both smoking and exposure to SHS. Including musculoskeletal disorders increased total cost to PPP$ 41.3 billion (1.25% of the combined GDP). CONCLUSION: The economic cost of smoking and SHS in the GCC states is relatively low compared with other high-income countries. Scaling-up implementation of evidence-based policies will prevent the evolution of a tobacco epidemic with its negative consequences for health and public finances.

Forecasting the type 2 diabetes mellitus epidemic and the role of key risk factors in Oman up to 2050: Mathematical modeling analyses.

AIMS/INTRODUCTION: To investigate and forecast type 2 diabetes mellitus epidemic, its related risk factors and cost in Oman by 2050. MATERIALS AND METHODS: An age-structured mathematical model was used to characterize type 2 diabetes mellitus epidemiology and trends in Oman between 1990 and 2050. The model was parametrized using current and quality data, including six nationally representative population-based epidemiological surveys for type 2 diabetes mellitus and its key risk factors. RESULTS: The projected type 2 diabetes mellitus prevalence increased from 15.2% in 2020 to 23.8% in 2050. The prevalence increased from 16.8 and 13.8% in 2020 among women and men to 26.3 and 21.4% in 2050, respectively. In 2020, 190,489 Omanis were living with type 2 diabetes mellitus compared with 570,227 in 2050. The incidence rate per 1,000 person-years changed from 8.3 in 2020 to 12.1 in 2050. Type 2 diabetes mellitus' share of Oman's national health expenditure grew by 36% between 2020 and 2050 (from 21.2 to 28.8%). Obesity explained 56.7% of type 2 diabetes mellitus cases in 2020 and 71.4% in 2050, physical inactivity explained 4.3% in 2020 and 2.7% in 2050, whereas smoking accounted for <1% of type 2 diabetes mellitus cases throughout 2020-2050. Sensitivity and uncertainty analyses affirmed these predictions. CONCLUSIONS: The type 2 diabetes mellitus epidemic in Oman is expected to increase significantly over the next three decades, consuming nearly one-third of the national health expenditure. The type 2 diabetes mellitus burden is heavily influenced by obesity. Interventions targeting this single risk factor should be a national priority to reduce and control the burden of type 2 diabetes mellitus in Oman.

The status of tobacco control in the Eastern Mediterranean Region: progress in the implementation of the MPOWER measures.

BACKGROUND: The World Health Organization (WHO) MPOWER measures are a set of highly effective tobacco control measures drawn from the WHO Framework Convention on Tobacco Control (FCTC), designed to help countries reduce the prevalence of tobacco use. The WHO Report on the Global Tobacco Epidemic is published biennially to monitor global implementation of these measures. AIMS: This review aimed to critically assess the status of MPOWER implementation in the Eastern Mediterranean Region. METHODS: Data were collected for WHO Reports on the Global Tobacco Epidemic, focusing on the most recent 2019 edition. Regional population coverage figures were calculated using this data and population figures for the countries of the Region. RESULTS: Between 2007 and 2018, for any MPOWER measure, there were 29 cases of countries progressing to the highest level of achievement; 23 cases of countries progressing to the intermediate levels from the lowest level; 12 cases of countries falling from the highest level; and 18 cases of countries falling to the lowest level. 57.7% of people are covered at the highest level for the monitoring measure; 63.7% for the smoke-free policies measure; 6.7% for the cessation measure; 60.7% for the health warnings measure; 37.4% for the mass media measure; 29.4% for the advertising bans measure; and 16.1% for the taxation measure. CONCLUSIONS: Countries must work comprehensively to improve tobacco control. Regional priorities should include lifting more people out of lowest level coverage for the health warnings and mass media measures, increasing taxation on tobacco products and improving access to cessation services.

Increasing Thyroid Cancer Incidence in Oman: A Joinpoint Trend Analysis.

OBJECTIVES: We sought to investigate the epidemiology of thyroid cancer and its trends in Oman over a 20-year period. METHODS: We analyzed all cases of primary thyroid cancer reported to the Oman National Cancer Registry between 1996 and 2015. Age-standardized incidence rates (ASR) were calculated using the World Standard Population. Joinpoint regression was used to assess trends and obtain annual percentage changes (APC) in incidence rates with 95% confidence intervals (95% CI) and p-values at the alpha = 0.050 level. Gender-specific APC was used to project thyroid cancer incidence rates in Oman over the next 20 years. Population attributable fraction was calculated for obesity and current non-smoking. RESULTS: A total of 1285 cases of primary thyroid cancer cases were registered in Oman between 1996 and 2015, with a female to male ratio of 4:1. In men, the ASR was 2.0 per 100 000 while in females it was 7.6 per 100 000 (p < 0.010). Over 80.0% of thyroid tumors were of a papillary type and 19.0% follicular type. Statistically significant trends for thyroid cancer were detected in women from 2008-2015 (APC = 14.3%, 95% CI: 8.0-20.9, p < 0.010) and among both genders (APC = 16.7%, 95% CI: 4.9-29.9, p < 0.010). If current trends continue, thyroid cancer incidence will increase to 3.1, 16.6, and 11.8 per 100 000 by 2040 in men, women, and both genders, respectively. Nearly 10.0% of thyroid cancer can be prevented by controlling obesity in the Omani population. CONCLUSIONS: Oman has had moderate incidence rates of thyroid cancer with an increasing trend among women. Since projections estimate that the rates of this disease will double in women over the next 20 years, health authorities should consider providing sufficient resources to manage this condition and establish prevention programs that address obesity as part of the strategy for the prevention and control of noncommunicable diseases.

Impact of Dual versus Single Antiplatelet Therapy on Major Cardiovascular Outcomes in Patients with Acute Coronary Syndrome in the Arabian Gulf.

OBJECTIVE: To evaluate the association of dual versus single antiplatelet therapy with major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS) in the Arabian Gulf. SUBJECTS AND METHODS: Data were analyzed from 3,559 patients with a diagnosis of ACS admitted to 29 hospitals in 4 Arabian Gulf countries (Bahrain, Kuwait, Oman, and United Arab Emirates) from January 2012 to January 2013. Dual antiplatelet therapy (DAPT), consisting of aspirin and clopidogrel, was compared to aspirin alone. MACE included 12-months cumulative stroke/transient ischemic attack (TIA), myocardial infarction (MI), all-cause mortality, and readmissions for cardiac reasons, post discharge. Analyses were performed using multivariable logistic regression. RESULTS: A total of 74% (n = 2,634) of the patients were on DAPT. At 12-month follow-up, patients on DAPT were significantly less likely to experience MACE events (adjusted OR [aOR] 0.73; 95% CI: 0.61-0.86; p < 0.001). Lower cardiovascular (CV) event rates were also consistent across the following MACE components; MI (aOR 0.66; 95% CI: 0.49-0.88; p = 0.005), all-cause mortality (aOR 0.69; 95% CI: 0.51-0.94; p = 0.018), and readmissions for cardiac reasons (aOR 0.79; 95% CI: 0.66-0.95; p = 0.011). Conversely, DAPT was adversely associated with increased risk of stroke/TIA (aOR 1.68; 95% CI: 1.05-2.69; p = 0.030). CONCLUSIONS: DAPT, compared to aspirin therapy alone, was generally associated with better CV outcomes after an ACS event. However, DAPT was adversely associated with increased risk of stroke/TIA in ACS patients in the Arabian Gulf.

Epidemiology of Lung Cancer in Oman: 20-Year Trends and Tumor Characteristics.

OBJECTIVES: We sought to investigate the epidemiology of lung cancer and its trends in Oman over 20 years. METHODS: We analyzed all cases of primary lung cancer reported to the Oman National Cancer Registry between 1996 and 2015. The World Standard Population was used to obtain age-standardized incidence rates (ASR) of lung cancer per 100 000. Analyses were conducted using univariate statistics. RESULTS: A total of 956 cases of primary lung cancer cases were registered in Oman between 1996 and 2015, with a male to female ratio of 3:1. In men, the ASR was 8.2 per 100 000, while in females it was 2.6 per 100 000 over the entire study period. There were no statistically significant differences in the ASR among men or women when the data was divided over three calendar periods (1996-2005, 2006-2015, and 1996-2015) (p = 0.332 and p = 0.577, respectively). There was also no increasing trend in the incidence of lung cancer. The risk of lung cancer onset commenced in the 30-34 year age group and the mean age at diagnosis was 60.0 years for men and 61.0 years for women. Adenocarcinoma was the most common type of lung cancer among Omanis with a higher proportion in females compared to males. CONCLUSIONS: Oman has one of the lowest incidence rates of lung cancer in the world with no evidence of an increasing trend of this cancer type. This could be attributed to low uptake of tobacco smoking among both sexes. National authorities should capitalize on this finding to avoid any future lung cancer epidemics especially those driven by tobacco use.

Impact of Clopidogrel on Mortality in Patients With Acute Heart Failure Stratified by Coronary Artery Disease: Findings From the Arabian Gulf Acute Heart Failure Registry (Gulf CARE).

We evaluated the impact of clopidogrel use on 3- and 12-months all-cause mortality in patients with acute heart failure (AHF) stratified by coronary artery disease (CAD) in patients admitted to 47 hospitals in 7 Middle Eastern countries with AHF from February to November 2012. Clopidogrel use was associated with significantly lower risk of all-cause mortality at 3 months (adjusted odds ratio [aOR], 0.61; 95% confidence interval [CI]: 0.42-0.87; P = .007) and 12 months (aOR, 0.61; 95% CI: 0.47-0.79; P < .001). When the analysis was stratified by CAD, the clopidogrel group in those with AHF and CAD was also associated with significantly lower risk of all-cause mortality at 3 months (aOR, 0.56; 95% CI: 0.38-0.83; P = .003) and 12 months (aOR, 0.58; 95% CI: 0.44-0.77; P < .001). However, in AHF patients without CAD, clopidogrel use was not associated with any survival advantages, neither at 3 months (aOR, 0.99; 95% CI: 0.32-3.11; P = .987) nor at 12 months (aOR, 0.80; 95% CI: 0.37-1.72; P = .566). Clopidogrel use was associated with short- and long-term all-cause mortality in patients with AHF and CAD. In AHF patients without CAD, clopidogrel use did not offer any survival advantage.

MPOWER, needs and challenges: trends in the implementation of the WHO FCTC in the Eastern Mediterranean Region.

BACKGROUND: WHO MPOWER aims to help countries prioritize tobacco control measures in line with the WHO Framework Convention on Tobacco Control. OBJECTIVES: This paper assessed the progress and challenges in implementing the 6 priority policies of MPOWER in countries of the WHO Eastern Mediterranean Region since 2011. METHODS: A checklist was developed and scores assigned based on the MPOWER indicators (maximum score 37). MPOWER data for the Region in the 2015 and 2017 tobacco control reports were extracted and scored. Data from similar analyses for 2011 and 2013 were also included. Countries were ranked by scores for each indicator for 2015 and 2017 and for overall scores for 2011 to 2017. RESULTS: The Islamic Republic of Iran, Egypt and Pakistan had the highest scores in 2015 (33, 29 and 27 respectively) and the Islamic Republic of Iran, Pakistan and Yemen had the highest scores in 2017 (34, 31 and 27 respectively). The indicators with the highest and lowest combined score for all countries were for advertising bans and compliance with smoke-free policies: 67 and 18 respectively in 2015, and 73 and 15 respectively in 2017. Most countries (15/22) had higher total scores in 2017 than 2015: Afghanistan, Bahrain and Syrian Arab Republic had the greatest increases. The total score for the Region increased from 416 out of a maximum score of 814 in 2011 to 471 in 2017. CONCLUSIONS: Although notable achievements have been made in the Region, many challenges to policy implementation remain and require urgent action by governments of the countries of the Region.

Impact of Angiotensin Converting Enzyme Inhibitors/Angiotensin Receptors Blockers on Mortality in Acute Heart Failure Patients with Left Ventricular Systolic Dysfunction in the Middle East: Observations from the Gulf Acute Heart Failure Registry (Gulf CARE).

AIMS: To evaluate the impact of Angiotensin-Converting Enzyme Inhibitors (ACEIs)/ Angiotensin Receptors Blockers (ARBs) on in-hospital, 3- and 12-month all-cause mortality in Acute Heart Failure (AHF) patients with left ventricular systolic dysfunction in 7 countries of the Middle East. METHODS AND RESULTS: Data was analysed from 2,683 consecutive patients admitted with AHF and Left Ventricular Ejection Fraction (LVEF) (<40%) from 47 hospitals from February to November 2012. Analyses were evaluated using univariate and multivariate statistics. The overall mean age of the cohort was 58±15, 72% (n=1,937) were males, 62% (n=1,651) had coronary artery disease, 57% (n=1,539) were hypertensives and 47% (n=1,268) had diabetes. Overall cumulative mortality at inhospital, 3- and 12-month follow-up was 5.8% (n=155), 12.6% (n=338) and 20.4% (n=548), respectively. Adjusting for demographic and clinical characteristics as well as medication in a multivariate logistic regression model, ACEIs were associated with lower risk of in-hospital mortality (adjusted odds ratio (aOR), 0.48; 95% Confidence Interval (CI): 0.25 to 0.94; p=0.031). At 3-month follow-up, both ACEIs (aOR, 0.64; 95% CI: 0.43 to 0.95; p=0.025) and ARBs (aOR, 0.34; 95% CI: 0.18 to 0.62; p<0.001) were associated with lower risk of mortality. Additionally, at 12-month follow-up, those prescribed ACEIs (aOR, 0.71; 95% CI: 0.53 to 0.96; p=0.027) and ARBs (aOR, 0.47; 95% CI: 0.31 to 0.71; p<0.001) were still associated with lower risk of mortality. CONCLUSION: ACEIs and ARBs treatments were associated with lower mortality risk during admission and up to 12-month of follow-up in Middle East AHF patients with left ventricular systolic dysfunction.