Commemorating 25 Years of Monitoring the Global Tobacco Epidemic

18.12.2024

Global

GATS, GYTS, TQS, TQS-Youth

In October 1999, the World Health Organization (WHO), the U.S. Centers for Disease Control and Prevention (CDC), and the Canadian Public Health Association (CPHA) launched the Global Tobacco Surveillance System (GTSS) by conducting the world’s first Global Youth Tobacco Survey (GYTS); a total of 12 countries successfully pilot-tested GYTS (Barbados, China, Costa Rica, Fiji, Jordan, Poland, Russian Federation, South Africa, Sri Lanka, Ukraine, Venezuela, and Zimbabwe)[1]. In October 2024, we celebrated 25 years of advancing public health by partnering with countries around the world to support surveillance, research, evaluation, and data dissemination to protect youth and adults from the harms of tobacco.

In its 25 years of service, the GTSS has become the global leader in monitoring youth and adult tobacco use and key tobacco control indicators. Currently, GTSS comprises four active components: GYTS, the Global Adult Tobacco Survey (GATS), Tobacco Questions for Surveys (TQS) and Tobacco Questions for Surveys of Youth (TQS-Youth). While the global tobacco landscape has changed drastically since 1999, the GTSS has risen to meet emerging challenges and continues to evolve and modernize its procedures. To further reflect on this, we interviewed two tobacco control experts who were involved in the early stages of the GTSS development to share their recollections and provide their perspectives and insights on global tobacco surveillance then and now.

[1] Global Youth Tobacco Surveillance, 2000_2007


(Left) Dr. Michael P. Eriksen is a Regents’ Professor and the founding Dean of the School of Public Health at Georgia State University (Atlanta, Georgia, USA).
(Right) Dr. Gary A. Giovino is a SUNY Distinguished Professor Emeritus at the University of Buffalo (Buffalo, New York, USA).

Tobacco Control Challenges in 1999
Reflecting on the state of tobacco control in 1999, Dr. Eriksen, Director of the Office on Smoking and Health at the CDC at that time, highlighted the critical need for reliable surveillance data then and now:

“The greatest pressing need for tobacco control was reliable surveillance data to document the extent of the problem and to guide potential solutions. The GYTS provided much-needed data to support tobacco control efforts globally and served as the foundation for the first edition of The Tobacco Atlas, which Judith Mackay and I published in 2002 and provided to every member state during the FCTC [Framework Convention on Tobacco Control] negotiations.”

In the United States, Dr. Giovino, former Chief of the Epidemiology Branch in CDC’s Office on Smoking and Health, described the concerning rise in youth smoking prevalence:

“Between 1991 and 1997, the prevalence of cigarette smoking among high school students [in the United States] increased from 27.5% to 36.4% (Youth Risk Behavior Surveillance System data). This led to substantial concern about youth smoking, which likely went up because of tobacco companies’ marketing campaigns in the late 1980s and early 1990s. So, in the United States in 1999, the most pressing issue was the prevalence of youth smoking and what could be done to reverse the spike in prevalence that occurred from 1991–1997.”

These early challenges underscored the importance of the GTSS in providing the data necessary to shape policies and interventions worldwide. Furthermore, the need for reliable data to address the tobacco use among youth and adults globally continues.

Progress and Achievements
Over the last 25 years, significant strides have been made in tobacco control. Dr. Giovino highlighted a remarkable achievement in reducing youth smoking prevalence:

“Of note is that the prevalence of cigarette smoking among high school students in the United States was 3.5% in 2023. This was a remarkable achievement, one that was made possible by developments such as the Master Settlement Agreement, which led to decreased marketing of cigarettes to youth, substantial increases in the price of cigarettes, public health campaigns, and document disclosure.”

The GTSS itself has been transformative, as noted by Dr. Eriksen:

“The advancement of evidence-based tobacco control policies and the corresponding reduction in tobacco use prevalence are among the most notable changes in the global tobacco landscape since 1999.”

Dr. Giovino emphasized the success of global collaboration through the GTSS:

“The emergence of the GTSS and, of course, the implementation of policies as endorsed by the Framework Convention on Tobacco Control (and MPOWER).”

Both Dr. Eriksen and Dr. Giovino suggested that early indicators of the GTSS’ success included widespread adoption and continued use of GYTS and GATS for systematically monitoring youth and adult tobacco use.

“The rapid and widespread adoption of GATS and GYTS, which was facilitated by strong partnerships with international agencies and member states. The delivery of collaborative training programs and ready availability of technical assistance was also essential.”

“That countries are repeating GYTS and GATS surveys over time. And that many are paying for the implementation of new surveys themselves.”

Since its implementation 25 years ago, the Global Youth Tobacco Survey has been conducted in over 190 countries/locations. As the GTSS expanded to include the Global Adult Tobacco Survey, Tobacco Questions for Surveys and Tobacco Questions for Surveys of Youth, GATS has been completed in 36 countries, TQS has been integrated into surveys in 105 countries, and TQS-Youth integrated into surveys in 3 countries.

Emerging Challenges
Despite progress, the tobacco landscape continues to evolve. Dr. Eriksen mentioned the proliferation of novel nicotine delivery systems as a key issue in 2024 and the challenge it may pose to the GTSS:

“The tobacco product landscape has changed dramatically in the last few years and surveillance systems and tobacco control policies must be modified to keep pace. This is a particular concern today for developed countries but will soon be a major issue throughout the world. There’s no question that the movement from combustible tobacco products (primarily cigarettes) to novel nicotine delivery systems will challenge the existing surveillance paradigm.”

Dr. Giovino echoed this concern, emphasizing the need for vigilance:

“I think the most pressing issue is the development of novel nicotine delivery systems. This requires constant vigilance as new products emerge… the tobacco industry will do whatever it can to increase profits, so vigilance in our work is always needed.”

The Road Ahead
Over the last 25 years, partnerships have been at the center of efforts to strengthen global tobacco surveillance around the world. The role that partnerships have played in the success of GTSS cannot be overstated. The GTSS would not be possible without sustained partnership with CDC, WHO, Ministries of Health and country-level partners, and international experts. These partnerships have been vital to ensuring GTSS upholds its aim to measure the progress of countries in fulfilling the requirements of the FCTC and MPOWER measures intended to assist in the country-level implementation of effective interventions to reduce the demand for tobacco. Financial support provided by the Bloomberg Initiative to Reduce Tobacco Use through the CDC Foundation with a grant from Bloomberg Philanthropies and the Bill & Melinda Gates Foundation have also provided much needed resources, support, and ongoing collaboration. The support from and collaboration with partners will remain foundational to the continued success of GTSS on the road ahead.

As we commemorate 25 years of the GTSS, it’s clear that the system and its engaged partners have played a vital role in advancing global tobacco control. As the global tobacco landscape evolves, the GTSS must remain adaptable to ensure that countries around the world have access to current, relevant data that will allow them to make informed decisions on how to protect their youth and adults from the harms of tobacco and preserve their right to breathe clean air.

The GTSS would like to thank Dr. Michael P. Eriksen and Dr. Gary A. Giovino for their contributions to this blog. Additional special thanks go to Brandy Maddox, Indu Ahluwalia, and Natalie Bishop for their contributions to the crafting of this blog.