Addressing the Changing Tobacco Control Landscape in Surveillance: Revised Global Adult Tobacco Survey (GATS) Comprehensive Standard Protocol

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Written by Dr. Indu Ahluwalia, PhD, MPH, the Chief of the Global Tobacco Control Branch in the Office on Smoking and Health of the U.S. Centers for Disease Control and Prevention.

Addressing the Changing Tobacco Control Landscape in Surveillance: Revised Global Adult Tobacco Survey (GATS) Comprehensive Standard Protocol

Globally, tobacco use kills more than 8 million people per year. Through the Global Tobacco Surveillance System (GTSS), the United States’ Centers for Disease Control and Prevention (CDC) provides technical assistance to countries to monitor the tobacco use epidemic and other tobacco-related indicators to assess progress, challenges, and opportunities for addressing  the availability and changing types of tobacco products. GTSS is the global surveillance system that systematically monitors tobacco use (smoked, smokeless, electronic products, and new and emerging products) and related key tobacco control indicators for both youths and adults.

The CDC has a long-term standing partnership with the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) Knowledge Hub on Surveillance to promote systematic collection of tobacco use data and to use that data to assist the Parties to the Convention to meet their obligations under Article 20. The CDC also works in close collaboration with WHO to assist countries to implement and measure the WHO’s MPOWER demand reduction framework, to assure that countries are moving towards the goal of 30% relative reduction in tobacco use by 2025.

To address the evolving tobacco landscape, a revised GATS Comprehensive Standard Protocol, 2020 was launched May 5, 2021. This protocol was revised in partnership with WHO, RTI International, Campaign for Tobacco Free Kids, CDC Foundation, and other global partners.

Revisions to the GATS protocol include changes to the GATS core questionnaire, the development of optional questions for countries to use and electronic data management updates.

Changes to the GATS Core Questionnaire:

  • Age of initiation of first smoking/first smokeless tobacco use
  • Electronic cigarette section.
    • Awareness, current use, ever use, ever daily use, length of daily use, and reasons for use.
  • Using electronic cigarettes and using heated tobacco products as methods for trying to stop smoking/using smokeless tobacco.
  • Bars/nightclubs, universities, and schools as places to measure exposure to secondhand smoke.
  • Revamped Media section on noticing tobacco advertisements, promotions, and sponsorships (TAPS).
    • Countries with multiple smoked and smokeless products will ask only one set of questions about TAPS.

Development of Optional Questions for Countries to Use:

  • Electronic cigarettes.
    • Age of initiation, time since quitting, brand, flavor, type, containing nicotine, money spent, satisfaction compared to cigarettes, and harmfulness compared to cigarettes.
  • Reasons for quitting or/trying to quit tobacco smoking/smokeless tobacco use.
  • Perception of difficulty to quit tobacco smoking/smokeless tobacco use.
  • Perception of damage to health in the future from tobacco smoking/smokeless tobacco use.
  • Measuring outdoor tobacco smoking on grounds of universities and schools.
  • Buying manufactured cigarettes with a capsule in the filter that releases a flavor.
  • Whether spending money on manufactured cigarettes resulted in not having enough money for household essentials.
  • Revamped Waterpipe (WP) module.
    • Smoking WP without tobacco, addiction, attempt to quit, intention to quit, and noticing and effect of health warnings.
  • Heated Tobacco Products (HTP) module—similar to electronic cigarette questions.

Electronic Data Management Updates

  • GATS General Survey System (GSS) questionnaire program updated
    • Core questionnaire updates
    • Optional questions and modules programmed
    • More quality assurance checks added
  • Case Management System (CMS) updated with a new, easier to use application
    • Tab views introduced
    • Fast forward to a specific question added
    • Screen background color choice given (dark vs. light)
    • “Information” button added to give quick view of database versions and field interviewer ID.

Analysis Package:

  • Developed standard indicators for new core survey questions.
    • Electronic cigarette indicators.
  • Updated standard fact sheet template.
    • Added electronic cigarette indicators.
  • Added the standard comparison fact sheet template (repeat GATS).
  • Added new standard country report tables for core questionnaire additions.
  • Updated standard set of country report comparison tables for repeat GATS countries.

Along with the revised GATS Protocol, the GATS Standard Protocol Training Series was also launched May 5, 2021. This 10-module training series is based on the standard presentation given during the GATS orientation and can be used to educate all GATS team members and partners about each part of the GATS implementation process.

The updated protocol strengthens the ability for countries to measure and assess the potential effect of the changing tobacco control landscape to provide evidence for enforcing the reduction measures outlined by the WHO FCTC. The WHO’s Global Action Plan for the Prevention and Control of Noncommunicable Diseases (NCDs) encourages countries to aim for a 30% relative reduction in tobacco use from their baseline prevalence by 2025. In addition, the United Nations Sustainable Development Goals also call for strengthening the implementation of the WHO FCTC to reduce tobacco use. The surveillance data from GTSS remains critical for many countries to measure progress in meeting the global targets and in improving public health.

About the author:

Indu Ahluwalia, PhD, MPH
U.S. Centers for Disease Control and Prevention

Dr. Ahluwalia is the Chief of the Global Tobacco Control Branch in the Office on Smoking and Health. She is responsible for guiding the scientific work of the branch, including tobacco surveillance, translation of data to usable information, and providing technical assistance for capacity enhancement.

Dr. Ahluwalia has been with CDC since 1995 when she joined the Epidemic Intelligence Service. From 2008 until she joined Office on Smoking and Health in 2015, Dr. Ahluwalia served as a Senior Scientist in the Division of Reproductive Health where she provided leadership to the PRAMS team and led projects with the March of Dimes and W.K. Kellogg Foundation. Her work building and sustaining partnerships has resulted in key improvements in using public health surveillance data to address gaps in services and programs.

Dr. Ahluwalia has a PhD in Health Behavior and Health Education from the University of North Carolina, at Chapel Hill and an MPH in Epidemiology and International Health from Yale University.