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    ABSTRACT: We updated and expanded a previous systematic literature review examining the impact of tobacco control interventions on socioeconomic inequalities in smoking. We searched the academic literature for reviews and primary research articles published between January 2006 and November 2010 that examined the socioeconomic impact of six tobacco control interventions in adults: that is, price increases, smoke-free policies, advertising bans, mass media campaigns, warning labels, smoking cessation support and community-based programmes combining several interventions. We included English-language articles from countries at an advanced stage of the tobacco epidemic that examined the differential impact of tobacco control interventions by socioeconomic status or the effectiveness of interventions among disadvantaged socioeconomic groups. All articles were appraised by two authors and details recorded using a standardised approach. Data from 77 primary studies and seven reviews were synthesised via narrative review. We found strong evidence that increases in tobacco price have a pro-equity effect on socioeconomic disparities in smoking. Evidence on the equity impact of other interventions is inconclusive, with the exception of non-targeted smoking cessation programmes which have a negative equity impact due to higher quit rates among more advantaged smokers. Increased tobacco price via tax is the intervention with the greatest potential to reduce socioeconomic inequalities in smoking. Other measures studied appear unlikely to reduce inequalities in smoking without specific efforts to reach disadvantaged smokers. There is a need for more research evaluating the equity impact of tobacco control measures, and development of more effective approaches for reducing tobacco use in disadvantaged groups and communities.
    Tobacco control 09/2013;
  • BMJ (online) 05/2013; 346:f3429.
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    ABSTRACT: INTRODUCTION: Poorer cancer survival in Indigenous populations contributes to health inequalities in both New Zealand and Australia. METHODS: We reviewed recent evidence of cancer treatment and outcomes among Māori and non-Māori New Zealanders and examined the range of factors that may contribute to poorer survival in Māori. RESULTS: There is clear evidence that Māori have poorer cancer survival compared with other ethnic groups, particularly European New Zealanders. Two recent studies show that Māori patients receive poorer quality treatment for cancers of the lung and colon, even after adjusting for patient factors. These findings suggest the need to consider how the health-care system as a whole may disadvantage Indigenous patients. DISCUSSION: We present a framework for considering how inequalities may arise in the delivery of cancer care, taking account of the health system as a whole - including the structure and organization of cancer services - as well as treatment processes and patient factors. A key feature of this framework is that it directs attention towards system-level factors affecting cancer care, including the location, resourcing and cultural focus of services. Our analysis suggests a need to look beyond individual patient factors in order to improve the quality and equity of cancer services and to optimize cancer survival in Indigenous populations.
    ANZ Journal of Surgery 12/2012;
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    ABSTRACT: INTRODUCTION: The increasingly inequitable impacts of tobacco use highlight the importance of ensuring developing countries' ongoing participation in global tobacco control. The WHO Framework Convention on Tobacco Control (FCTC) has been widely regarded as reflecting the high engagement and effective influence of developing countries. METHODS: We examined participation in FCTC governance based on records from the first four meetings of the Conference of the Parties (COP), comparing representation and delegate diversity across income levels and WHO regions. RESULTS: While attendance at the COP sessions is high, there are substantial disparities in the relative representation of different income levels and regions, with lower middle and low income countries contributing only 18% and 10% of total meeting delegates, respectively. In regional terms, Europe provided the single largest share of delegates at all except the Durban (2008) meeting. Thirty-nine percent of low income countries and 27% of those from Africa were only ever represented by a single person delegation compared with 10% for high income countries and 11% for Europe. Rotation of the COP meeting location outside of Europe is associated with better representation of other regions and a stronger presence of delegates from national ministries of health and focal points for tobacco control. CONCLUSIONS: Developing countries face particular barriers to participating in the COP process, and their engagement in global tobacco control is likely to diminish in the absence of specific measures to support their effective participation.
    Tobacco control 11/2012;
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    ABSTRACT: BACKGROUND TO THE DEBATE: Tobacco continues to kill millions of people around the world each year and its use is increasing in some countries, which makes the need for new, creative, and radical efforts to achieve the tobacco control endgame vitally important. One such effort is discussed in this PLOS Medicine Debate, where Simon Chapman presents his proposal for a "smoker's license" and Jeff Collin argues against. Chapman sets out a case for introducing a smart card license for smokers designed to limit access to tobacco products and encourage cessation. Key elements of the smoker's license include smokers setting daily limits, financial incentives for permanent license surrender, and a test of health risk knowledge for commencing smokers. Collin argues against the proposal, saying that it would shift focus away from the real vector of the epidemic-the tobacco industry-and that by focusing on individuals it would censure victims, increase stigmatization of smokers, and marginalize the poor.
    PLoS Medicine 11/2012; 9(11):e1001343.
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    ABSTRACT: OBJECTIVE: To systematically review studies of tobacco industry efforts to influence tobacco tax policies. METHODS: Searches were conducted between 1 October 2009 and 31 March 2010 in 14 databases/websites, in relevant bibliographies and via experts. Studies were included if they focused on industry efforts to influence tobacco tax policies, drew on empirical evidence, were in English and concerned the period 1985-2010. In total, 36 studies met these criteria. Two reviewers undertook data extraction and critical appraisal. A random selection of 15 studies (42%) was subject to second review. Evidence was assessed thematically to identify distinct tobacco industry aims, arguments and tactics. RESULTS: A total of 34 studies examined industry efforts to influence tax levels. They suggest the tobacco industry works hard to prevent significant increases and particularly dislikes taxes 'earmarked' for tobacco control. Key arguments to counter increases are that tobacco taxes are socially regressive, unfair and lead to increased levels of illicit trade and negative economic impacts. For earmarked taxes, the industry also frequently tries to raise concerns about revenue allocation. Assessing industry arguments against established evidence demonstrates most are unsupported. Key industry tactics include: establishing 'front groups', securing credible allies, direct lobbying and publicity campaigns. Only seven studies examined efforts to influence tax structures. They suggest company preferences vary and tactics centre on direct lobbying. CONCLUSIONS: The tobacco industry has historically tried to keep tobacco taxes low using consistent tactics and misleading arguments. Further research is required to explore efforts to influence tax structures, excise policies beyond the USA and recent policies.
    Tobacco control 08/2012;
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    ABSTRACT: The WHO Framework Convention on Tobacco Control (FCTC) demonstrates the international political will invested in combating the tobacco pandemic and a newfound prominence for tobacco control within the global health agenda. However, major difficulties exist in managing conflicts with foreign and trade policy priorities, and significant obstacles confront efforts to create synergies with development policy and avoid tensions with other health priorities. This paper uses the concept of policy coherence to explore congruence and inconsistencies in objectives, policy, and practice between tobacco control and trade, development and global health priorities. Following the inability of the FCTC negotiations to satisfactorily address the relationship between trade and health, several disputes highlight the challenges posed to tobacco control policies by multilateral and bilateral agreements. While the work of the World Bank has demonstrated the potential contribution of tobacco control to development, the absence of non-communicable diseases from the Millennium Development Goals has limited scope to offer developing countries support for FCTC implementation. Even within international health, tobacco control priorities may be hard to reconcile with other agendas. The paper concludes by discussing the extent to which tobacco control has been pursued via a model of governance very deliberately different from those used in other health issues, in what can be termed 'tobacco exceptionalism'. The analysis developed here suggests that non-communicable disease (NCD) policies, global health, development and tobacco control would have much to gain from re-examining this presumption of difference.
    Tobacco control 03/2012; 21(2):274-80.
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    ABSTRACT: The past decade has witnessed a tremendous growth in the scale and policy influence of civil society in global health governance. The AIDS 'industry' in particular opens up spaces for active mobilisation and participation of non-state actors, which further crystallise with an ever-increasing dominance of global health initiatives. While country evaluations of global initiatives call for a greater participation of 'civil society', the evidence base examining the organisation, nature and operation of 'civil society' and its claims to legitimacy is very thin. Drawing on the case of one of the most visible players in the global response to HIV epidemic, the Global Fund to Fight AIDS, Tuberculosis and Malaria, this article seeks to highlight the complex micropolitics of its interactions with civil society. It examines the nature of civil society actors involved in the Fund projects and the processes through which they gain credibility. We argue that the imposition of global structures and principles facilitates a reconfiguration of actors around newer forms of expertise and power centres. In this context, the notion of 'civil society' underplays differences and power dynamics between various institutions and conceals the agency of outsiders under the guise of autonomy of the state and people.
    Global Public Health 01/2012; 7(5):437-51.
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    ABSTRACT: In May 2007, the Instituto Carso de la Salud-now Instituto Carlos Slim de la Salud (ICSS)-was endowed with US$500 million to focus on priority health issues in Latin America, notably issues of 'globalisation and non-communicable diseases'. ICSS was soon criticised, however, on the grounds that its funding was derived from tobacco industry profits and that its founder Carlos Slim Hélu remained an active industry principal. Collaboration with ICSS was said to run counter to the WHO Framework Convention on Tobacco Control. The Institute's then Executive President Julio Frenk disputed these charges. This research employs an archive of tobacco industry documents triangulated with materials from commercial, media, regulatory and NGO sources to examine the financial relations between Slim and the tobacco industry. The paper analyses Slim's continuing service to the industry and role in ICSS. It demonstrates a prima facie conflict of interest between ICSS's health mission and its founder's involvement in cigarette manufacturing and marketing, reflected on ICSS's website as a resounding silence on issues of tobacco and health. It is concluded that the reliance of international health agencies upon the commercial sector requires more robust institutional policies to effectively regulate conflicts of interest.
    Tobacco control 12/2010; 19(6):e1-9.
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    ABSTRACT: Racial and ethnic inequalities in colon cancer treatment have been reported in the United States but not elsewhere. The authors of this report compared cancer treatment in a nationally representative cohort of Maori (indigenous) and non-Maori New Zealanders with colon cancer. On the basis of cancer registry data, 301 Maori patients and 329 randomly selected non-Maori patients were identified who were diagnosed with colon cancer between 1996 and 2003. Medical notes were reviewed, and surgical and oncology treatments were compared by indigenous status. Maori and non-Maori patients had similar rates of surgical resection, although Maori patients were less likely to undergo extensive lymph node clearance and were more likely to die during the postoperative period. Maori patients were significantly less likely to receive chemotherapy for stage III disease (relative risk [RR], 0.69; 95% confidence interval [CI], 0.53-0.91) and were more likely to experience a delay of at least 8 weeks before starting chemotherapy (RR, 1.98; 95%CI, 1.23-3.16). Treatment disparities were not explained by differences in tumor characteristics or patient comorbidity. Maori New Zealanders with colon cancer were less likely to receive adjuvant chemotherapy and experienced a lower quality of care compared with non-Maori patients. The authors concluded that attention to health system factors is needed to ensure equal access and quality of cancer treatment for indigenous and ethnic minority populations.
    Cancer 07/2010; 116(13):3205-14.
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