Specific Aims

According to the Centre of Health Politics & Services in Romania, 37% of the general population smokes and 41% of youth ages 13-15 have ever tried cigarettes. Exposure to secondhand smoke is high in Romania, with 59% of young people reporting that their parents smoke.

The dearth of tobacco research in Romania is remarkable. The research that exists has been predominately cross sectional and localized to the country’s capital of Bucharest. There is scant or non-existent data among adults, special populations (e.g., Roma), clinical services, regulation (e.g. clean indoor air), or economics (e.g. cost of tobacco-related morbidity and mortality). We propose to fill these scientific voids by translating a highly successful tobacco research and capacity building project from Hungary to Romania.

The Romanian cohort of mentored scientists represents a wide range of disciplines, including psychology, sociology, economics, public health and medicine. Collectively this group will carry out seven research projects with five overarching emphases: (1) tobacco prevention and cessation; (2) reduction of secondhand smoke exposure, (3) inclusion of vulnerable populations, (4) intervention-oriented research, and (5) strategically designed so that the results will inform programmatic and policy change.

The leadership team (Foley, Ábrám, Balázs) will guide mentored scientists in Romania in strategic planning and logic model development at the inception of the grant. Hungarian scientists and American scientists who participated in the earlier capacity building project will serve as scientific consultants to the Romanian scientists. Institutional capacity will be built using conceptual frameworks for action research and trans disciplinary science. The Hungarian-American team will offer workshops in Romania on core competencies of research methodology. The training will be matched to the Romanian projects, also taking into account best practices in tobacco control research and translating research to practice, including the WHO MPOWER framework and case studies in successful comprehensive tobacco control programs (e.g., California).

This capacity building model, which was highly successful in Hungary, builds capacity not only in Romania but also among the mentors. The initiative is specifically expected to build the Hungarians’ capacity as Central and Eastern European leaders in tobacco research as they move from the role of mentee to mentor. At the same time, we expect multi-lateral collaborations to emerge, leading to important new international partnerships in tobacco research. Hungarian and American scientists will learn about the history and tradition of tobacco research and control in Romania, understand the gaps in tobacco knowledge that exist, and collaborate with stakeholders and scientists engaged in the tobacco control movement in Romania. By implementing a shared learning process embedded in mutual learning and respect, participating scientists in the three countries will be better equipped to collaborate on scientifically rigorous and meaningful research to curb tobacco use in Romania.

In carrying out the Aims of the grant, we will hold ourselves accountable to the following performance indicators: 1) an international partnership will be formed to advance tobacco research in Romania; 2) a strategic plan will be established to guide the funded Romanian scientists in designing their studies and in translating the findings into policy and practice; 3) the Romanian scientists will meet the proposed aims of their research projects; 4) the Romanian scientists will increase their research-related knowledge and skills, and will show an increased ability to conduct independent and scientifically rigorous tobacco research; 5) the Hungarian scientists will increase their skills in mentoring and capacity building, and will continue to establish their reputation as tobacco researchers and leaders; 6) the U.S. scientists will increase their understanding of tobacco issues in Romania; and 7) research findings will be broadly disseminated and will lead to innovative tobacco control interventions to reduce tobacco use in Romania.

Significance

Romania is the 9th largest country in the EU and has the 7th largest population. Tobacco science in Romania is underdeveloped and the country lacks a strategy to build the capacity of scientists to design and conduct rigorous tobacco control research.

This project will: 1) build the capacity of Romanian scientists to conduct high-quality tobacco research; 2) create institutional capacity for a sustainable network of scholars dedicated to tobacco research; 3) use research to inform and transform practices and policies to curb tobacco use in Romania; and 4) facilitate the emergence of Hungarian scientists as leaders of tobacco control research in Central and Eastern Europe (CEE). The current project will focus special attention on the Transylvania region of Romania.

Tobacco Control in Romania: High rates of smoking persist in Romania despite relatively strong tobacco control policy. Romania ratified the WHO Framework Convention on Tobacco Control (FCTC) in 2006. Romanian Law #394/2002 restricts advertising of tobacco products, regulates the sale of tobacco to youth, and requires licensing for manufacturing, importing, and exporting tobacco products. Romania heavily taxes tobacco, with ≥75% of the total retail price attributable to taxation. In October 2011, the government considered smoking bans in all closed public spaces, with exceptions for clubs, restaurants and discos.

The usefulness of taxation as a policy instrument in Romania may be limited because: (1) taxes are already high, and (2) circumvention of tobacco control by smuggling appears to be endemic. Given the ready availability of black-market tobacco products, other programmatic and legislative opportunities need to be seized in order to reduce tobacco use and tobacco-related morbidity and mortality in Romania. Gaps in fulfilling the FCTC goals include lack of enforcement of existing policies, lack of comprehensive clean indoor regulation, and lack of utilization of existing cessation services.

The Health Ministry is the main organizing body in Romania responsible for reducing tobacco morbidity and mortality. In addition to working with public health authorities, this group is trying to increase the use of the Tel Verde Stop Fumat (i.e., QuitLine). The Romanian Network for Smoking Prevention is an umbrella NGO working to bring various stakeholders together specifically focused on closing loopholes in clean indoor air legislation and earmarking tobacco tax revenue for NGO anti-tobacco activity. Universities participate in tobacco research to a very small extent, especially outside the capital city of Bucharest. The national resources available for tobacco research in Romania are limited, which creates fiscal and personnel challenges to establishing scientific evidence for tobacco control.

Tobacco Science in Romania: Published tobacco research from Romania focuses primarily on individual-level, cross-sectional surveys related to tobacco use. The following review summarizes what is known about tobacco use among population subgroups and special topics in tobacco control, while at the same time pointing out how the mentored research projects will fill these gaps.

24% of youth in grades 7-10 report that they use tobacco (28% boys and 20% girls), and 25% initiated smoking prior to age 10. Among 13-15 year old never smokers, almost 1 in 3 say that they are likely to initiate smoking in the next year (an upward trend from 2004), with girls reporting a greater likelihood than boys (32% vs. 21%). Only 70% of schools have a policy prohibiting use among school personnel and less than half (46%) offer non-classroom activities to teach tobacco prevention. Limited research has been conducted to develop and test youth tobacco-prevention programs in Romania.

Very limited research has examined the link between SES and tobacco use in Romania. It is reported that low education and blue collar occupation were significant risk factors for lung cancer among men in CEE countries, and the relationship between occupational status and lung cancer risk was highest among Romanian men.

Tobacco use among medical students was 33% in 1997 and higher among practicing physicians (estimates ranging from 40% to 63%) in 2000. Data on providers’ willingness and capacity to provide cessation services is lacking, but is hypothesized to be low based on their tobacco use behavior. While there are no data on readiness to quit among the adult population, among youth,

54% of current smokers want to quit and 72% tried to stop smoking during the past year.

Available studies indicate that Romanians are widely exposed to SHS. Smoking was observed in 40 of the 41 public venues observed in Romania. A global comparative study of tobacco smoke-derived particle levels in indoor public spaces found that Romania ranked 2nd highest out of 32

countries (386 μg/m3). The WHO’s target air quality guidelines are 25 μg/m3 24-hour mean.

Tobacco taxes have risen at a faster pace than inflation in Romania. Despite a proactive tax strategy to reduce consumption, tobacco use remains very high, at least in part because of pervasive smuggling. It is estimated that 37% of the tobacco products consumed in Romania are

smuggled, which equates to 1B Euro in lost tobacco tax revenue per year. The economic losses, however, due to tobacco morbidity and mortality have not been calculated.

In sum, the mentored research projects proposed in this application were strategically designed to fill critical gaps in tobacco science in Romania, taking into account the political and economic context.

Fogarty International Center - National Institutes of Health (NIH)

The Fogarty International Center is dedicated to advancing the mission of the National Institutes of Health (NIH) by supporting and facilitating global health research conducted by U.S. and international investigators, building partnerships between health research institutions in the U.S. and abroad, and training the next generation of scientists to address global health needs.

The Fogarty International Center's vision is a world in which the frontiers of health research extend across the globe and advances in science are implemented to reduce the burden of disease, promote health, and extend longevity for all people.

The Fogarty International Center, part of the U.S. National Institutes of Health, supports basic, clinical and applied research and training for U.S. and foreign investigators working in the developing world. Since its formation more than 40 years ago, Fogarty has served as a bridge between NIH and the greater global health community - facilitating exchanges among investigators, providing training opportunities and supporting promising research initiatives in developing countries. Over the last four decades, about 5,000 scientists worldwide have received significant research training through Fogarty Programs.

Today, Fogarty funds some 400 research and training projects involving more than 100 U.S. universities. The U.S. scientists, in turn, collaborate with colleagues in numerous foreign countries, most of them in the developing world. Fogarty also convenes the best scientific minds around the world to address critical global health research problems such as polio eradication, the impact of climate change on disease outbreaks and strengthening research capacity in Africa.

Davidson College

Davidson College is a nationally recognized, highly selective, undergraduate liberal arts college of 1,700 students. The average range for SATs of our students is 1930 to 2160. Davidson College is among the top fifty liberal arts colleges in the U.S. in the percentage of graduates who later earn Ph.D.s in science. Twenty-three Davidson graduates have been selected Rhodes Scholars, which ranks the College fifth among liberal arts colleges in the country.

Davidson’s mission is excellence in undergraduate education. A central focus is active inquiry and learning, including independent research. Because there are no graduate students at Davidson, undergraduates are an integral part of the research team and have frequent and important interactions with faculty mentors and research participants. Through classroom and hands-on research experiences, students gain an excellent understanding of the values of team-based science as well as the ethical conduct of research. Furthermore, an emphasis on active inquiry and hands-on learning helps prepare these students for futures in research, medicine, and public health and provides an excellent infrastructure for research among the liberal arts faculty.

The presence of multiple active research groups on campus creates a dynamic research atmosphere and promotes a culture of scholarship in the natural and social sciences, with a special interest in the health sciences. This culture is valued and strongly supported by the College’s investment in the Grants & Contracts office, which provides pre- and post-award grants management, as well as its investment in the premedical and medical humanities programs.

Dr. Foley is the Associate Director of the Medical Humanities Program at Davidson College. This Program promotes an interdisciplinary understanding of health and health care. It enables students to appreciate the strengths and limits of the natural sciences, social sciences and humanities as they seek to explain and to achieve a measure of control over disease, illness, and suffering. The concentration helps students to grasp how legal, economic, and political institutions influence the production, distribution and delivery of health care services. It also provides students with the analytical and ethical skills necessary to apply the principles of scientific integrity in biomedical research.

Davidson strives for distinction among national liberal arts colleges in its emphasis on understanding the world at large and preparing students for the challenges of national and international leadership. Recognizing that international awareness is critical in today's interdependent world, the college inaugurated the Dean Rusk International Studies Program, in 1985 to provide a cornerstone for efforts to enhance international offerings on campus and to "give each student, first, an informed awareness of our whole planet, and second, direct knowledge of at least one foreign area." The International Studies Program fosters initiatives designed to ensure that Davidson students leave the college with a broad understanding of all dimensions of global affairs—political, cultural, social, economic, and historical. It sponsors visits by experts on international issues, hosts conferences and cultural events, and counsels students about international travel, internships, and careers. It encourages pursuit of an international curriculum through the college's concentration in International Studies, major at the Center for Interdisciplinary Studies, area studies, or courses in various academic departments.

Project leaders

Prof. Dr. Kristie Long Foley

She was Principal Investigator of “Building Capacity for Tobacco Research in Hungary”. The Hungarian Ministry of Health has recognized this grant as the leading tobacco research effort in the country, and findings from this initiative have been used to guide tobacco control programs and policy in the country. The capacity-building model Dr. Foley and her team initiated in Hungary has excellent potential to increase capacity for tobacco research and policy and to reduce tobacco-related morbidity and mortality in low- and middle-income countries. Dr. Foley is responsible for the overall scientific and administrative aspects of the Romanian initiative as well, including 7 independent research projects. She will take the lead for all scientific and administrative aspects of this study, including coordination of the scientific team and oversight of scientific activities.

Dr. Foley has a Ph.D. in Health Behavior and Health Education from The UNC Gillings School of Global Health and completed an NCI-funded post-doctoral fellowship in cancer prevention and control. Dr. Foley is Professor of Medical Humanities at Davidson College. In this position, she provides teaching, research and administrative functions in the areas of research ethics, global public health, public health policy and ethics, and epidemiology. She has a 9-month faculty appointment and teaches 3 courses per year, allowing sufficient time to engage in research. Prior to joining Davidson College in April 2008, Dr. Foley served as the Associate Director of Research for the Tobacco Intervention Program at Wake Forest University School of Medicine and was Assistant Professor of Social Sciences and Health Policy. She has served as principal investigator and co-principal investigator in several successful grants: to develop a comprehensive, web-based curriculum in the basic and clinical sciences of tobacco for medical students, a community capacity building grant to reduce non-sacred tobacco use among the Haliwa-Saponi Indian Tribe, a grant to evaluate the contextual factors that contribute to inadequate treatment, surveillance, and survival patterns among poor individuals with colon cancer etc.

Prof. Dr. Zoltán Ábrám

He is the local coordinator of the project being professor at the University of Medicine and Pharmacy from Targu Mures where he is teaching hygiene, public health and health education. He teaches also at the University of Sapientia, Targu Mures branch and at Bod Peter Nurse School. He has studied the lifestyle and the health state of the population since fifteen years, with an emphasis on smoking, alcohol consumption and drug abuse in school children and young adults. He is a member of several professional societies and a leader in non-governmental organizations, managing scientific meetings and initiating health education activities, especially among youth. Dr. Abram has published several environmental hygiene and health education books and brochures on different health prevention topics, including smoking. Some of his research themes relate to smoking habits and health effects among youth and the lifestyle and health status of the adult population in Romania.

Prof. Dr. Péter Balázs

He is Vice Director of the Department of Public Health of Faculty General Medicine at Semmelweis University in Budapest. He was the President of the General Council in Preventive Medicine and Public Health from 2005-2008 and currently serves as a member of this committee. He is also vice chairman of the Hungarian Public Health Society and an active member in the Board of Hungarian Society for History of Medicine. In 1999, he organized and implemented training courses for future health managers of Kosovo after the NATO military action, mandated by the International Organisation of Migration (IOM). In 2006-2007, he headed a study group mandated by the Ministry of Health in Hungary in collaboration with the WHO-European Regional Bureau. From 2007 to 2012, he served as Consortium Principal Investigator of “Building Capacity for Tobacco Research in Hungary”. His personal interest in this project stems from his expertise in organizational capacity building and bridging science and public policy. He has published manuscripts in tobacco research, and is a contracted guest professor of the postgraduate training school in Health Management of the University of Debrecen/Hungary and teaches courses in health system research and health policy every year at the University of Medicine & Pharmacy, Targu Mures, Romania . Dr. Balázs will serve as both scientific advisor to the project related to pregnancy, smoking, and secondhand smoke and as administrative advisor to Prof. Dr. Zoltan Abram in Romania. 

Published: 07.10.2014.