TECHNICAL NOTE I
Evaluation of existing policies and compliance
To ensure consistency and comparability between the WHO Report on the Global Tobacco Epidemic, 2008 and this 2009 report, the data collection and analysis methodology used are based on last year’s report. Some of the methodology employed in the first report has been revised and strengthened for the present report. Where revisions have been made, data from the first report have been reanalysed so that the results are comparable between years.
The methodology employed for this year’s report is described in this technical note.
The questionnaire form used for data collection can be found at www.who.int/ tobacco/mpower/en.
Data collection
Consistent with the first report, data were collected using a survey instrument to assess countries’ implementation of the six MPOWER measures. The questionnaire for the 2009 report contained 131 questions and was constructed using Microsoft Excel.
The use of an electronic data collection mechanism was introduced to streamline the data collection and data analysis processes. The questionnaire had two main objectives:
to collect information ? on the status of each MPOWER measure as of 31 December 2008;
? to correct information published in the previous report.
Thus, for each question, the data collector was asked to confirm or correct the value that was published in the first report as well as to indicate any changes in the status of the MPOWER measure as of 31 December 2008. Where measures pertained to legislation passed in the country, data collectors were asked to provide electronic copies of the legislation.
The data collection method was pre-tested in English in six countries (one country in each region). Data for this report were collected electronically from 100% of the participating countries.
Data validation
The data validation process occurred in two stages. The first stage was an internal validation conducted at WHO: questionnaires were checked for logical inconsistencies; any inconsistencies found were reviewed by WHO staff and resolved by checking the WHO FCTC Parties reports1, the documentation provided by governments, or by communicating directly with the country data collector. The second stage was validation of the data by the ministry of health of the reporting country.
To facilitate review by the ministries of health, a summary sheet was generated for each country and was sent to the appropriate ministry for review prior to the close of the report database.
Further details about data processing procedures are available from the Tobacco Free Initiative at WHO.
Data analysis
The summary measures developed for the WHO Report on the Global Tobacco Epidemic, 2008 were carefully revised in order to more precisely assess the implementation of the six MPOWER measures, to better identify the tobacco control policy areas in each country that require attention, and to target efforts limitations on the effectively on them. The implementation status of the six measures was classified by grouping countries into four categories in each area (five categories in the case of smoke-free environments).
In order to compare the status between 2007 and 2008, the 2007 groups were recalculated using a revised grouping methodology (except for the Monitoring groups, where the information was not available to recalculate the 2007 baseline).
Hence, grouping data published in the first report differ from the recalculated 2007 groups published in this report.
Monitoring
The section of the questionnaire devoted to measuring monitoring asked the data collector to note the most recent smoking prevalence survey data available and collect the following information:
? how recent the survey was;
? whether the survey was representative of the country’s population;
? whether it covered adults, youth or both;
? whether the survey was repeated at least every five years (survey periodicity).
Surveys were considered recent if the data were collected in 2003 or later. Surveys were considered representative if the sample was representative of the national population.
Surveys were considered periodic if they were conducted at least once every five years. Surveys were considered “adult surveys” if participants were above 15 years of age. Surveys were considered “youth surveys” if all participants were between 11 and 19 years of age.
For this year’s report, the groupings for the Monitoring indicator have been revised to reflect the additional information collected on the survey periodicity. Periodicity of surveys of at least every five years is included in the highest category in addition to the requirements of recent and representative data for adults and youth. Because of this, some countries that fell in the highest category in the first report (defined as those having recent and representative data only) do not fall in the highest category in this second report. The groupings for the Monitoring indicator are listed below.
No known data or no recent* data or data that are not both recent* and not representative**
Recent* and representative** data for either adults or youth Recent* and representative** data for both adults and youth Recent*, representative** and periodic*** data for both adults and youth
* Data from 2003 or later.
** Survey sample representative of the national population.
*** Occurring at least every five years. Smoke-free legislation
There is a wide range of places and institutions where it is possible to prohibit smoking. Smoke-free legislation can take place at the national or subnational level. This year’s report includes items to measure national legislation as well as legislation in subnational jurisdictions.
The assessment of subnational smoke-free legislation includes large jurisdictions that are first-level administrative boundaries (first administrative subdivisions of a country) and, in addition, large cities with over 5 million inhabitants or encompassing more than 20% of the country’s population.
This year’s questionnaire included items measuring whether smoke-free laws existed in each of the following places at either the national or subnational level:
? health-care facilities;
? educational facilities other than universities;
? universities;
? government facilities;
? indoor offices;
? restaurants;
? pubs and bars;
? public transport.
For this year’s report, groupings for the Smoke-free Legislation indicator have been revised so that they are based on the numbers of places and institutions where smoking is completely prohibited.
In addition, countries where at least 90% of the population are covered by complete subnational smoke-free legislation are grouped in the top category. Subnational smoke-free legislation is considered “comprehensive” when smoking in all of the public places assessed is completely banned. In several countries, in order to significantly expand the creation of smoke-free places, including restaurants and bars, it was politically necessary to include exceptions to the law that allowed for the provision of designated smoking rooms. The requirements for designated smoking rooms are so technically complex and stringent that, for practical purposes, few or no establishments are expected to implement them. Because no data were requested on the number of complex designated smoking rooms actually constructed, it is not possible to know whether these laws have resulted in the complete absence of such rooms, as intended. For this reason, these few countries have not been categorized in the analyses for this section.
The groupings for the Smoke-free Legislation indicator are listed below.
Data not reported/not categorized
Up to two public places completely smoke-free
Three to five public places completely smoke-free
Six to seven public places completely smoke-free
All public places completely smokefree (or at least 90% of the population covered by complete subnational smoke-free legislation)
Future data collection efforts will include such measures, as well as incorporate evaluation of legislation enforcement.
As noted at the beginning of this report, as well as in the WHO FCTC Article 8 guidelines and several other governmental and nongovernmental reports, ventilation and other forms of designated smoking areas do not fully protect from the harms of second-hand tobacco smoke, and the only laws that provide complete protection are those that result in the complete absence of smoking in all public places.
Tobacco dependence treatment
Despite the low cost of quit lines, few low- or middle-income countries have implemented such programmes. Thus, national toll-free quit lines are included as a qualification only for the highest category. Reimbursement for tobacco dependence treatment is considered only for the top two categories, to take the tight national budgets of many lower-income countries into consideration.
The top three categories reflect varying levels of government commitment to the availability of nicotine replacement therapy and cessation support. The groupings for the Tobacco Dependence Treatment indicator are listed below.
Data not reported
None NRT* and/or some cessation services** (neither cost-covered) NRT* and/or some cessation services** (at least one of which is cost-covered) National quit line, and both NRT* and some cessation services** costcovered * Nicotine replacement therapy.
** Smoking cessation support available in any of the following places: health clinics or other primary care facilities, hospitals, office of a health professional, the community.
Health warnings
The section of the questionnaire devoted to measuring health warnings asked the data collector to note the following information about the cigarette pack warnings: the mandated size of ? the warnings, as a percentage of the front and back of the cigarette pack;
? whether specific health warnings are mandated;
? whether the warnings appear on individual packages as well as on any outside packaging and labelling used in retail sale;
? whether the warnings describe specific harmful effects of tobacco use on health;
? whether the warnings are large, clear, visible and legible (e.g. specific colours and font style and sizes are mandated);
? whether the warnings rotate;
? whether the warnings are written in (all) principal language(s) of the country.
The size of the warning on front and back of the cigarette pack was averaged to calculate the percentage of the total pack surface area that is covered by the warnings. This information was combined with the warning characteristics to construct the groupings for the Health Warnings indicator. The groupings for the Health Warnings indicator are listed below. Data not reported
No warning or warning covering <30% of pack surface ≥30%* but no pictures or pictograms and/or other appropriate characteristics** 31%–49%* including pictures or pictograms and other appropriate characteristics** ≥50%* including pictures or pictograms and appropriate
characteristics** * average of the front and back of the cigarette pack. ** ? Specific health warnings mandated;
? appearing on individual packages as well as on any outside packaging and labelling used in retail sale;
? describing specific harmful effects of tobacco use on health;
? are large, clear, visible and legible (e.g. specific colours and font style and sizes are mandated);
? rotate;
? written in (all) principal language(s) of the country. Bans on advertising, promotion and sponsorship
The section of the questionnaire devoted to measuring bans on advertising, promotion and sponsorship asked the data collector to note whether advertising bans covered the following types of advertising:
? national television and radio;
? local magazines and newspapers;
? billboards and outdoor advertising;
? point of sale;
? free distribution of tobacco products in the mail or through other means;
? promotional discounts;
? non-tobacco products identified with tobacco brand names (brand extension);
? brand names of non-tobacco products used for tobacco products;
? appearance of tobacco products in television and/or films;
? sponsored events.
The first four bans listed are considered “direct” advertising bans, and the remaining six are considered “indirect” bans. Complete bans on tobacco advertising, promotion and sponsorship usually start with bans on direct advertising in national media and progress to bans on indirect advertising as well as promotion and sponsorship.
Bans that cover national TV, radio and print media were used as the basic criteria for the two lowest groups, and the remaining groups were constructed based on how comprehensively the law covers the forms of direct and indirect bans included in the questionnaire.
The groupings for the Bans on Advertising, Promotion and Sponsorship indicator are listed below.
Data not reported
Complete absence of ban, or ban that does not cover national television (TV), radio and print media Ban on national TV, radio and print media only Ban on national TV, radio and print media as well as on some but not all other forms of direct* and/or indirect** advertising Ban on all forms of direct* and indirect** advertising
* Direct advertising bans:
? national television and radio;
? local magazines and newspapers;
? billboards and outdoor advertising;
? point of sale.
** Indirect advertising bans:
? free distribution of tobacco products in the mail or through other means;
? promotional discounts;
? non-tobacco products identified with tobacco brand names (brand extension);
? brand names of non-tobacco products used for tobacco products;
? appearance of tobacco products in television and/or films;
? sponsored events. Tobacco tax levels
Countries are grouped according to the percentage contribution of taxes to the retail price. Taxes assessed include excise tax, value added tax (sometimes called “VAT”), import duty (when the cigarettes were imported) and any other taxes levied.
Only the price of the most popular brand of cigarettes is considered. In the case of countries where different levels of taxes applied to cigarettes are based on either length, quantity produced or type (e.g. filter vs. non-filter), only the rate that applied to the most popular brand is used in the calculation.
Given the lack of information on countryand brand-specific profit margins of retailers and wholesalers, their profits were assumed to be zero (unless provided by the national data collector). The groupings for the Tobacco Tax indicator are listed below.
Data not reported
≤ 25% of retail price is tax
26–50% of retail price is tax
51–75% of retail price is tax
>75% of retail price is tax
National tobacco control programmes
Classification of countries’ national tobacco control programmes is based on the existence of a national agency with responsibility for tobacco control objectives as a minimum criterion for group 3. Countries with at least 5 full-time equivalent staff members working at the national agency with responsibility for tobacco control meet the criteria for the highest group.
The groupings for the National Tobacco Control Programme indicator are listed below.
Data not reported No national agency or no national objectives on tobacco control Existence of national agency with responsibility for tobacco control objectives with no or < 5 full-time equivalent staff members
Existence of national agency with responsibility for tobacco control objectives and at least 5 full-time equivalent staff members Compliance assessment Compliance with national and comprehensive subnational smoke-free legislation as well as with advertising, promotion and sponsorship bans (covering both direct and indirect marketing) was assessed by a group of five national experts, who assessed the compliance in these two areas as “minimal”, “moderate” or “high”. These five experts were selected by the national data collector according to the following criteria:
? person in charge of tobacco prevention in the country’s ministry of health, or the most senior government official in charge of tobacco control or tobaccorelated conditions;
? the head of a prominent nongovernmental organization dedicated to tobacco control;
? a health professional (e.g. physician, nurse, pharmacist or dentist) specializing in tobacco-related conditions;
? a staff member of a public health university department;
? the Tobacco Free Initiative focal point of the WHO country office.
The experts performed their assessments independently through an interview with the national data collector. Summary scores were calculated by WHO from the five individual assessments by assigning two points for highly enforced policies, one point for moderately enforced policies and no point for minimally enforced policies, with a potential minimum of 0 and maximum of 10 points in total from these five experts. The country-reported answers to each survey question are listed in Appendix IV. Appendix I summarizes this information. Compliance scores are represented separately (i.e. compliance is not included in the calculation of the grouping categories). As noted above, future data collection efforts will include a more extensive assessment of legislation enforcement, and this assessment will be used to construct the categories of MPOWER measures.
1 Parties report on the implementation of the WHO Framework Convention on Tobacco Control according to Article 21. The objective of reporting is to enable Parties to learn from each other’s experience in implementing the WHO FCTC. Parties’ reports are also the basis for review by the COP of the implementation of the Convention. Parties submit their initial report two years after entry into force of the WHO FCTC for that Party, and then every subsequent three years, through the reporting instrument adopted by COP. For more information please refer to http://www.who.int/fctc/reporting/ en/.
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