Cross-sectional study of the associations between the implementation of the WHO FCTC tobacco advertising, promotion and sponsorship bans and current e-cigarette use among youth from countries with different income levels.

BACKGROUND: The WHO Framework Convention on Tobacco Control (WHO FCTC) Article 13 requires countries to ban tobacco advertising, promotion and sponsorship (TAPS), and bans are recommended to cover electronic cigarettes (e-cigarettes). We examined youth e-cigarette prevalence by TAPS regulations in countries with different income levels. METHODS: We analysed data on 165 299 respondents from 48 countries with 2016/2018 WHO FCTC implementation reports and 2016-2019 Global Youth Tobacco Survey. We used multilevel logistic regressions to examine associations between TAPS regulations and current e-cigarette use, stratified by country income. RESULTS: About 1 in 10 respondents was currently using e-cigarettes. Respondents in countries with TAPS bans on the internet were less likely to use e-cigarettes (adjOR=0.58; 95% CI 0.39 to 0.86) than youth in countries without such bans. In lower middle-income and low-income countries, bans on displaying tobacco products at the point of sale (adjOR=0.55; 95% CI 0.34 to 0.90), bans on product placement (adjOR=0.44; 95% CI 0.28 to 0.69) and strength of additional TAPS measures were associated with lower prevalence of e-cigarette use among students. Being taught about the dangers of the use of tobacco in school was associated with lower odds of e-cigarette use. No differences in the use of e-cigarettes were observed by types of TAPS among respondents in high-income countries. CONCLUSIONS: Strengthening implementation of TAPS policies and assuring they cover new and emerging products, online channels and points of sales are essential, especially in lower income countries. Maintaining tobacco health education is also important to protect youth from e-cigarette use.

How to make better use of scientific knowledge for cancer prevention.

Cancer prevention research has produced profound scientific knowledge that has led to the development of several evidence-based prevention strategies. But do these research outcomes lead to preventive action in real life? Many factors contribute to the so-called 'implementation gap' between prevention recommendations and their application and adherence, including individual actions and behaviour, health service structures and political actions. This article discusses factors underlying the implementation gap in both clinical- and population-based prevention. Understanding how these factors contribute to the implementation gap is important for planning successful cancer prevention strategies, as well as generally achieving disease prevention.

The North Karelia Project: Prevention of Cardiovascular Disease in Finland Through Population-Based Lifestyle Interventions.

The North Karelia Project was started in 1972 as a response to the high cardiovascular mortality among men in North Karelia, Finland's easternmost province. Prevalent cardiovascular disease risk factors in the province included elevated serum cholesterol, hypertension, and smoking. Through a sociobehavioral framework utilizing community-based interventions and national-level policy changes and legislation, the project targeted lifestyle changes as a means to alleviate cardiovascular disease risk factors. Diet recommendations included minimizing the use of saturated fats and decreasing salt intake. Another target of the project was to reduce the prevalence of smoking. As a result of the lifestyle interventions that continued beyond the initial 5 years of the project and then expanded to all of Finland, there were significant reductions in serum cholesterol levels, hypertension, smoking prevalence, and cardiovascular disease mortality. The North Karelia Project demonstrates that successful population-based lifestyle interventions serve as a sustainable public health solution to the growing chronic disease burden.

Impact of the WHO FCTC on tobacco control: perspectives from stakeholders in 12 countries.

BACKGROUND: The WHO Framework Convention on Tobacco Control (WHO FCTC), the first WHO treaty, entered into force in 2005. In April 2015, a seven-member independent expert group (EG) was established by a decision of the FCTC Conference of the Parties to assess the impact of the Treaty in its first decade.One component of the EG's methodology was to gather evidence on WHO FCTC impact from Parties themselves. This paper presents findings from 12 country missions on how the FCTC impacted progress on tobacco control. METHODS: Between November 2015 and May 2016, EG members conducted missions in 12 countries representing each of the six WHO regions and the four World Bank economic development levels. In each country, the EG interviewed a broad range of stakeholders to assess the extent to which the FCTC had contributed to tobacco control. The primary objective was to assess whether tobacco control measures would have been developed or passed, or implemented at all, or as quickly, if there had been no FCTC. Through this counterfactual inquiry, the EG sought to determine the FCTC's causal role. CONCLUSION: The FCTC was reported to have made contributions along the entire policy/regulation process: the development of a measure, building legislative and political support for a measure and its implementation. These stakeholder perspectives support the conclusion that the FCTC has played a pivotal role in accelerating and strengthening the implementation of tobacco control measures, although tobacco industry interference continues to be a significant obstacle to further advancement.

Thirty-eight-year trends of educational differences in smoking in Finland.

OBJECTIVES: Smoking is declining, but it is unevenly distributed among population groups. Our aim was to examine the socio-economic differences in smoking during 1978-2016 in Finland, a country with a history of strict tobacco control policy. METHODS: Annual population-based random sample data of 25-64-year-olds from 1978 to 2016 (N = 104,315) were used. Response rate varied between 84 and 40%. In addition to logistic regression analysis, absolute and relative educational differences in smoking were examined. RESULTS: Smoking was more prevalent among the less educated but declined in all educational groups during the study period. Both absolute and relative differences in smoking between the less and highly educated were larger at the end of the study period than at the beginning. Cigarette price seemed to have a larger effect on the smoking among the less educated. CONCLUSIONS: Socio-economic differences in smoking among the Finnish adult population have increased since the 1970s until 2016. Further actions are needed, especially focusing on lower socio-economic positions, to tackle inequalities in health. They should include support for smoking cessation and larger cigarette tax increases.

WHO FCTC as a Pioneering and Learning Instrument Comment on "The Legal Strength of International Health Instruments - What It Brings to Global Health Governance?"

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) is a unique global health instrument, since it is in the health field the only instrument that is international law. After the 10 years of its existence an Independent Expert Group assessed the impact of the FCTC using all available data and visiting a number of countries interviewing different stakeholders. It is quite clear that the Treaty has acted as a strong catalyst and framework for national actions and that remarkable progress in global tobacco control can be seen. At the same time FCTC has moved tobacco control in countries from a pure health issue to a legal responsibility of the whole government, and on the international level created stronger interagency collaboration. The assessment also showed the many challenges. The spread of tobacco use, as well as of other risk lifestyles, is related to globalization. FCTC is a pioneering example of global action to counteract the negative social consequences of globalization. A convention is not an easy instrument, but the FCTC has undoubtedly sparked thinking and development of other stronger public health instruments and of needed governance structures.

" Nature step" to prevent noncommunicable inflammatory disease.

The prevention of many diseases has significantly improved by intervening in known risk factors. However, the causes of the increase in allergy and type 1 diabetes are unknown. These diseases are often associated with a low-grade inflammation and immunological imbalance. The lifestyle and environment of urbanized populations have changed causing imbalance in the human normal flora and affecting immune regulation. We discuss everyday factors affecting immune regulation, using allergy as an example. Health may be promoted through the "nature step", by supporting the connection between humans and nature.

The P4 Health Spectrum - A Predictive, Preventive, Personalized and Participatory Continuum for Promoting Healthspan.

Chronic diseases (i.e., noncommunicable diseases), mainly cardiovascular disease, cancer, respiratory diseases and type-2-diabetes, are now the leading cause of death, disability and diminished quality of life on the planet. Moreover, these diseases are also a major financial burden worldwide, significantly impacting the economy of many countries. Healthcare systems and medicine have progressively improved upon the ability to address infectious diseases and react to adverse health events through both surgical interventions and pharmacology; we have become efficient in delivering reactive care (i.e., initiating interventions once an individual is on the verge of or has actually suffered a negative health event). However, with slowly progressing and often 'silent' chronic diseases now being the main cause of illness, healthcare and medicine must evolve into a proactive system, moving away from a merely reactive approach to care. Minimal interactions among the specialists and limited information to the general practitioner and to the individual receiving care lead to a fragmented health approach, non-concerted prescriptions, a scattered follow-up and a suboptimal cost-effectiveness ratio. A new approach in medicine that is predictive, preventive, personalized and participatory, which we label here as "P4" holds great promise to reduce the burden of chronic diseases by harnessing technology and an increasingly better understanding of environment-biology interactions, evidence-based interventions and the underlying mechanisms of chronic diseases. In this concept paper, we propose a 'P4 Health Continuum' model as a framework to promote and facilitate multi-stakeholder collaboration with an orchestrated common language and an integrated care model to increase the healthspan.

Why Did North Karelia-Finland Work?: Is it Transferrable?

Successful prevention of cardiovascular diseases in the North Karelia Project and Finland has drawn international attention, particularly as cardiovascular diseases and more generally noncommunicable diseases have become the leading cause of premature mortality in the world. The questions have often been asked about what were the main reasons for success and whether or not the experience could be transferred elsewhere. The main lesson is that the possibilities and potential of cardiovascular prevention are great. The principles of population-based prevention are universal and are expressed in the strategies of World Health Organization. But, the practical implementation of the preventive work must be tailored to local cultural, social, and administrative (political) situations. This paper discusses many elements of the work in North Karelia and Finland that were likely important for success.

Creating a pro-active health care system to combat chronic diseases in Sri Lanka: the central role of preventive medicine and healthy lifestyle behaviors.

INTRODUCTION: The current burden and future escalating threat of chronic diseases, constitutes the major global public health challenge. In Sri Lanka, cardiovascular diseases account for the majority of annual deaths. Data from Sri Lanka also indicate a high incidence and prevalence of pre-diabetes and diabetes; 1 in 5 adults have elevated blood sugar in Sri Lanka. It is well established that chronic diseases share four primary behavioral risk factors: 1) tobacco use; 2) unhealthy diet; 3) physical inactivity; and 4) harmful use of alcohol. AREAS COVERED: Evidence has convincingly shown that replacing these behavioral risk factors with the converse, healthy lifestyle characteristics, decrease the risk of poor outcomes associated with chronic disease by 60 to 80%. In essence, prevention or reversal of these behavioral risk factors with effective healthy lifestyle programing and interventions is the solution to the current chronic disease crisis. Expert commentary: Healthy lifestyle is medicine with global applicability, including Sri Lanka and the rest of the South Asia region. This policy statement will discuss the chronic disease crisis in Sri Lanka, its current policies and action implemented to promote healthy lifestyles, and further recommendations on preventive medicine and healthy lifestyle initiatives that are needed to move forward.

Background, Principles, Implementation, and General Experiences of the North Karelia Project.

The extremely high mortality of cardiovascular diseases in the 1960s in Finland, particularly in the Eastern Province of North Karelia and especially that of coronary heart disease in men, caused great concern among the local population. Action to reduce the problem was demanded in a petition signed in 1971 by the representatives of the population. In response, the North Karelia Project was launched in 1972 to carry out a comprehensive preventive project, first only in North Karelia as a national pilot (1972 to 1977), and thereafter continuing in North Karelia but at the same time transferring the experiences to a national level. The intervention was based on the at-that-time relatively new scientific information on the main causal risk factors. A comprehensive population-based intervention was carried out, aiming especially at the reduction of the high levels of serum cholesterol, blood pressure, and tobacco use, emphasizing general dietary changes and smoking reduction. A comprehensive monitoring and evaluation program was designed and implemented to learn from the experience in preparation for national and international use. Presented here are the background, principles, and general experiences of this project, which has made major contributions both to the contemporary public health work for the prevention and control of heart disease and noncommunicable diseases and for research in the area.

Changes in Serum Cholesterol and Diet in North Karelia and All Finland.

Finland in the 1960s, and especially North Karelia in the eastern part of the country, had the highest cardiovascular mortality in the world. The classical cardiovascular risk factors were all common, but serum cholesterol level was extremely high because of the very high intake of saturated fats, mainly from dairy products. The North Karelia Project was started as a comprehensive preventive program to reduce serum cholesterol levels by reducing the intake of saturated fats and increasing the intake of polyunsaturated fats in the whole population. Cross-sectional population surveys were done in North Karelia and nearby Kuopio province every 5 years starting in 1972. After 1982, surveys were started in 2 other areas. Blood cholesterol was measured from serum samples, and diet was assessed by a questionnaire in all surveys-since 1982 by 3-day food record, since 1997 by 24-hour recall, and since 2002 by 48-hour recall. Between 1972 and 2012, the population in North Karelia reduced serum cholesterol from 6.92 mmol/l to 5.46 mmol/l (21%) in men and from 6.81 mmol/l to 5.37 mmol/l (21%) in women. In men, serum cholesterol level reduced more in North Karelia than in the reference province of Kuopio during the first 5 years from 1972 to 1977. Since that time, changes in serum cholesterol level have been very similar in different parts of the country. Saturated fats were reduced from 20% of energy intake to 12% in 2007 but increased from 2007 to 2012 to 14%. In conclusion, serum cholesterol reduction by dietary changes is feasible on the population level but requires active work and large-scale cooperation between all the meaningful sectors in the society.