Tobacco control policies and the health of Adolescents in Pakistan (TAP): a multi-method study

在全球范围内，烟草每年造成800多万人死亡。大多数人在青春期就开始吸烟。这样做会增加他们患上哮喘等健康问题的机会，而持续这样做到成年会增加他们患癌症、心血管和呼吸系统问题以及过早死亡的风险。因此，防止吸食烟草是公共卫生的优先事项。强有力的政策导致高收入国家的青年吸纳人数急剧下降。然而，大多数低收入和中等收入国家(LMIC)都落后了。例如，在巴基斯坦，十分之一的青少年吸烟，而在英国，这一比例为40%。这些差异突显出缺乏强有力的政策来保护青少年免受廉价烟草和烟草行业咄咄逼人的营销的影响。巴基斯坦与烟草有关的疾病负担沉重，每年有超过16万人死于烟草，但它是世界上最便宜、最不受监管的烟草市场之一。巴基斯坦政府再次承诺履行其保护青少年免受烟草侵害的义务。烟草控制政策路线图包括增税和引入普通包装的计划。应巴基斯坦政府建立的国家烟草控制小组的要求，我们提出了一项研究计划，旨在为普通包装政策和未来的税收改革提供信息，以减少青少年对烟草的吸收和使用。根据既定的政策研究方法，我们将进行五项补充研究。在前三项研究中，我们将：进行烟盒收集活动，以探索包装如何被用于推广烟草产品，并评估对当前健康警示法规的遵守情况(研究1)；采访那些为烟草控制政策提供建议、告知、立法和倡导烟草控制政策的人，以评估他们对普通包装和增税的支持程度和看法(研究2)；以及在焦点小组讨论中探索青少年对烟草包装的暴露和认知、对普通包装的反应以及烟草价格(研究3)。对于研究3，为了确保将上学的青少年和不上学的青少年包括在内，这是巴基斯坦的一个重要问题，我们将举办8个有在校学生参加的焦点小组和8个有失学青少年的重点小组。在先前研究的基础上，在研究4中，我们将对10-16岁的青少年进行调查。我们的目标是在中学招聘5670人，在社区招聘2880人。我们将收集与烟草有关的态度和行为的数据。我们还将评估人们对在巴基斯坦销售的一系列烟草包装的看法，以及对包装上的健康警告和普通包装的反应。将收集烟草购买行为的数据，包括产品替代和品牌转换。除了收集对政策提供信息至关重要的数据外，这项调查还将为未来评估任何法规和税收改革提供基线。在调查的同时，在研究5中，我们将估计由于烟草价格上涨而导致的青少年烟草使用量的预测下降，以便为巴基斯坦的烟草税收政策提供参考。为了开展这项工作，我们的团队包括流行病学家、统计学家、临床医生、卫生经济学家、行为学家和政治学家。我们的专长是政策研究、烟草控制、研究翻译、能力加强和领先的研究联合体。除卫生部外，我们还通过政策论坛与民间社会倡导者、临床医生、学者和立法者合作，并通过青年咨询小组与青少年合作。在我们利益相关者和传播渠道的帮助下，我们计划向巴基斯坦和其他国家的烟草控制政策提供信息。通过帮助防止年轻人染上烟草，我们的研究将有助于减轻LMIC与烟草相关的疾病负担。

Globally, tobacco is responsible for over 8 million deaths each year. Most people start using tobacco during adolescence. Doing so increases their chances of developing health problems, such as asthma, and continuing to do so into adulthood increases their risk of cancers, cardiovascular and respiratory problems, and premature death. Therefore, preventing tobacco uptake is a public health priority. Robust policies have resulted in a steep decline in youth uptake in high-income countries. However, most low and middle-income countries (LMIC) lag behind. For example, one in 10 adolescents use tobacco in Pakistan compared to one in 40 in the UK. Such differences highlight a lack of robust policies to protect adolescents from cheap tobacco and aggressive tobacco industry marketing. Pakistan is heavily burdened by tobacco-related diseases, with over 160,000 tobacco deaths per year, yet it is one of the world's cheapest and most unregulated tobacco markets. Pakistan's government has reinvigorated its commitment to fulfil its obligation to protect adolescents from tobacco. A tobacco control policy roadmap includes plans to raise taxes and introduce plain packaging. Following a request from Pakistan's National Tobacco Control Cell, established by the government to enhance tobacco control efforts in Pakistan, we propose a research programme that aims to inform plain packaging policy and future tax reforms in order to reduce tobacco uptake and use among adolescents. Based on established methods in policy research, we will conduct five complementary studies. For the first three studies we will: conduct a pack collection exercise to explore how the packaging is being used to promote tobacco products, and to assess compliance with current health warning regulations (Study 1); interview those who advise, inform, legislate and advocate for tobacco control policies to gauge their level of support for and views on plain packaging and tax rises (Study 2); and explore adolescent's exposure to, and perceptions of, tobacco packaging, and response to plain packaging, and tobacco prices in focus group discussions (Study 3). For Study 3, to ensure the inclusion of adolescents who attend school and adolescents who do not, a significant issue in Pakistan, we will conduct eight focus groups with school attenders and eight with those out of school.Building on the earlier studies, in Study 4 we will conduct a survey with adolescents aged 10-16 years-old. We aim to recruit 5,670 in secondary schools and 2,880 in community settings. We will collect data on tobacco-related attitudes and behaviours. We will also assess perceptions of a range of tobacco packs on sale in Pakistan, and response to the health warnings that are on packs, and to plain packaging. Data on tobacco purchase behaviours, including product substitution and brand switching, will be collected. In addition to collecting data that will be crucial for informing policies, the survey will also provide a baseline for the future evaluation of any regulations and tax reforms. In parallel with the survey, in Study 5 we will estimate the predicted fall in tobacco use in adolescents as a result of a tobacco price increase to inform tobacco tax policies in Pakistan. To deliver this work, our team includes epidemiologists, statisticians, clinicians, health economists, behavioural and political scientists. Our expertise is in policy research, tobacco control, research translation, capacity strengthening and leading research consortia. In addition to the Ministry of Health, we are partnering with civil society advocates, clinicians, academics and legislators through a policy forum and with adolescents through youth advisory panels. With the help of our stakeholders and dissemination channels, we plan to inform tobacco control policies in Pakistan and beyond. By helping to prevent uptake among youth, our research will contribute to reducing the tobacco-related disease burden in LMIC.