Disease surveillance, a key epidemiological approach, involves the collection, analysis, and interpretation of an enormous volume of data to identify disease trends and patterns, any change in pattern possibly the outbreaks, their etiologies’ along with their monitoring and control.1 Like other LMICs Pakistan has a wide spectrum of disease reporting systems like vertical programs, dashboards, disease registries HMIS and DHIS with Integrated Disease Surveillance and Response System IDSRS being the most recent approach.2 The major limitation of IDSRS currently is its focus on communicable diseases as only 33 “notifiable diseases” which are all communicable ones; are being tracked in this system at public sector primary and secondary health care facilities.2 It explains the limited scope in terms of its geographical span, generalizability and representativeness. Thus forth, indicating a long way to go for a reporting system of a country with 230 million inhabitants primarily using private healthcare services.3,4 Other challenges of DHIS or IDSRS include lack of coordination between different disease reporting systems particularly the vertical programs and disease registries using different reporting forms and different interfaces at all levels.5 Challenges with utility of health information system are multifold and disintegration and isolated data systems is only one of these. 6 It is simplistic to assume that there exists a straight relationship between information generating evidence and thus paving the way to policy for improving the health. However, in real situations such simple linear relationships are hardly existent.7,8 It is particularly important for utilizing this information at the higher levels of health system where data and decision-making are linked in a more extremely complex manner and many externalities come into play while embarking upon strategic decision making. More so when competing interests are there between available resources and infrastructure and different stakeholders interact. In order to strengthen the country’s health information systems, it is essential to undertake context specific system strengthening integrated approaches.8 Through various reporting systems, undoubtedly our country is in possession of tons of data none the less what needs to be emphasized is its mere availability alone does not guarantee that it will be used for improved decision-making. 4 Once the health information system has started converting data into information, the information produced needs to be used regularly at all levels. This conversion of making sense out of the primary data to information and then to evidence requires an appropriate and simple toolkit of targeted methods aimed at providing relevant feedback. One of such approach to enhance data sharing across multiple reporting systems is “Minimal Data Set” (MDS) in public health surveillance. This refers to a standardized data collection of essential and minimal elements necessary to monitor and analyze the trends within a population.6 It's a carefully drafted set of variables that are considered fundamental for effective surveillance without unnecessary redundancy. It not only delineates what data is to be collected but also about how that data is analyzed, and used for public health policies and interventions at national level. MDS can be one of the effective ways to start with, extemporize and expand with the expansion in country’s capacity to cater the whole data at a central place.7 MDS is aimed at identifying and developing targeted sets of data for use through its guiding principles such as leveraging upon already existing reporting systems the first one.7,8 Reducing the amount of information is its second guiding principle hence termed as “minimum dataset”. 6,7 This reduces the burden of data collection and thus improves data quality. Thirdly it should principally be establishing a consensual information architecture as a shared resource at national and subnational levels in view of devolution and respect for provincial autonomy for an enhanced participation and improving information practices and enabling the data sharing at all levels.8 Fourth guiding principle shall be building broad-based consensus and stakeholder involvement essentially underscoring the importance of building upon existing initiatives as strengthening should not take place in a vacuum.7 Furthermore, it requires a realistic target- oriented approach in a way that takes into consideration that data integration across various systems is designed in realistic manner with targets that can be achieved within available resources and capacities-the fifth guiding principal. Last but not the least the sixth principal entails that MDS shall be aimed at gradual and incremental expansion and not entail total overhaul of the existing system with a long-term vision.

The present study was designed to investigate whether Moringa oleifera leaf extract (MOLE) modified the changes caused by interactive exposure of nanoparticles and heavy metals in various hepatotoxicity parameters. Sixty-three Sprague Dawley rats weighed 105 +/- 5 g were assigned into seven groups (n=9) each. Group I was control (C). Groups II and III were given moringa with low 2% and high 3 % doses. Group IV consisted of low doses of silver nanoparticles (100 mg/kg) and arsenic (10.25mg/kg). Group V embraced high doses of silver nanoparticles (150 mg/kg) and arsenic (16.4mg/kg). Group VI comprised low and group VII consisted of high doses of chemicals and MOLE as described above. Doses were administered orally and daily for three months. Three rats from each group were euthanized and evaluated for various parameters after 4th, 8th, and 12th weeks of the experiment. Results revealed that silver nanoparticles and Arsenic exposure at low and high doses induced severe necrotic histopathological changes in liver tissue accompanied by remarkably escalated levels of ALT, AST, ALP, and oxidative stress marker (TBARS). Furthermore, albumin, total protein, SOD, CAT, GPX, and GSH levels were significantly depleted in each successive three-month treatment. Concurrent treatment of silver nanoparticles and arsenic-intoxicated rats with MOLE prevented tissue injury through improving the liver's cellular integrity, correcting liver proteins/enzymes and inhibiting TBARS levels by activating the antioxidant enzymes in a dose-dependent manner. Therefore, MOLE administration demonstrated a therapeutic role against hepatotoxic effects of silver nanoparticles and arsenic, which are related to its antioxidant capabilities.

Background:Pakistan, with its diverse points of entry, faced several challenges with implementing the International Health Regulations (IHR) ethically during the COVID-19 pandemic. Aim:To explore the perceptions of point of entry health workers regarding the ethics challenges in implementing the IHR during the COVID-19 pandemic. Methods:From December 2022 to March 2023, this qualitative study conducted 10 focused group discussions and key informant interviews with 40 participants from 10 points of entry in Pakistan and reviewed COVID-19 containment guidelines. The data generated were transcribed, translated into English and analysed manually. The thematic analysis focused on the core ethics principles, including optimization of population health versus autonomy, distributive justice versus equity, trustworthiness versus privacy and confidentiality, and the impact of sanctions and restrictions on vulnerable populations. Results:The study identified ethics challenges relating to containment policies, public health measures (testing, quarantine and isolation), travel restrictions, equitable resource distribution, and emergency operations. These challenges were grouped under 3 main categories, according to the IHR thematic areas: prevent, detect and respond. Respondents said it was difficult to balance between the public health measures and individual rights, address discrimination and stigmatization, and ensure fairness and justice in vaccine distribution and travel restrictions. Conclusion:Navigating ethics challenges relating to IHR implementation during health emergencies requires transparent communication, cultural sensitivity, and a commitment to equity and justice. It is important to incorporate ethics considerations into national emergency response plans to guide decision-making, safeguard individual rights and promote collective wellbeing.

Avian influenza viruses, particularly H5N1, H7N9, and H9N2, pose significant threats to avian and human populations through zoonotic transmission, as they have potential to change their genetic material through mutations. Symptoms of Avian Influenza ranges from mild to severe, mainly respiratory problems in both and muscle aches, fatigue in humans. This review highlights the molecular mechanisms by which the virus infects host cells, emphasizing the roles of hemagglutinin (HA) and neuraminidase (NA) in viral entry and release. Biochemical processes involved in viral replication, immune responses, and cytokine production are discussed, with a detailed examination of how antiviral drugs like neuraminidase and polymerase inhibitors disrupt these processes. Outbreak of AIV can cause mass culling results in massive economic loss, trade disruptions, and consumer reductions. The review also addresses the challenges posed by antiviral resistance and outlines novel therapeutic strategies, including combination therapies, vaccine advancements, and host-directed treatments. With an interdisciplinary “One Health” approach, this paper underscores the need for enhanced biosecurity, international cooperation, and continued research to mitigate the global impact of avian influenza.

Introduction Atherosclerotic cardiovascular disease (ASCVD) is a major cause of morbidity, mortality and health expenditures worldwide. Despite having higher ASCVD in the Pakistani population, data on subclinical coronary atherosclerosis in young Pakistanis remain scarce. The PAKistan Study of prEmature coronary atHerosclerosis in young AdulTs (PAK-SEHAT) aims to assess the prevalence, severity and determinants of subclinical coronary atherosclerosis among Pakistani men (35–60 years) and women (35–65 years) free of clinically symptomatic ASCVD and will assess 5-year rates of ASCVD events.Methods and analysis PAK-SEHAT is an ongoing prospective cohort study with 2000 participants from all provinces of Pakistan who will be interviewed at the baseline along with phlebotomy, measurement of carotid intima-media thickness (CIMT) and coronary CT angiography (CCTA). Phlebotomy will be repeated at 2.5 years, whereas CIMT and CCTA will be repeated at 5 years. We will report the frequency of maximal coronary stenosis ≥50% and ≥70%, number of coronary vessels with plaque and the number of coronary segments affected per participant on CCTA. We will use Cox proportional hazards regression models to evaluate the association between baseline characteristics and incident ASCVD events during follow-up. These associations will be presented as HRs with 95% CIs.Ethics and dissemination The study protocol was approved by the Tabba Heart Institute Institutional Review Board (THI/IRB/FQ/22-09-2021/016). All study procedures are consistent with the principles of the Declaration of Helsinki. Findings of the study will be disseminated via peer-reviewed publications and conference presentations.Trial registration number NCT05156736.

INTRODUCTION:Medication nonadherence leads to poor health outcomes, frequent complications, and high economic impact. Our objective was to assess the determinants of adherence to medication regimens among patients with hypertension.METHODS:We conducted a cross-sectional study of patients with hypertension attending the cardiology clinic of a tertiary care hospital in Islamabad, Pakistan. Data were collected by using semistructured questionnaires. A score of 7 or 8 on the 8-item Morisky Medication Adherence Scale was classified as good adherence, 6 as moderate, and less than 6 as nonadherence. Logistic regression was performed to determine covariates associated with medication adherence.RESULTS:We enrolled 450 patients with hypertension (mean age, 54.5 y; SD, 10.6). Medication adherence was good among 115 (25.6%) patients and moderate among 165 (36.7%); 170 (37.8%) patients were nonadherent. Most patients (72.7%) had uncontrolled hypertension. Nearly half (49.6%) were unable to afford monthly medication. In bivariate analysis, nonadherence was associated with female sex (odds ratio [OR], 1.44; P = .003) and long waiting times in the health care facility (OR, 2.93; P = .005); the presence of comorbidities (OR, 0.62; P = .01) was associated with good adherence. In multivariate analysis, nonadherence was associated with unaffordability of treatment (OR, 2.25; P = .002) and uncontrolled hypertension (OR, 3.16; P < .001). Good adherence determinants included adequate counseling (OR, 0.29; P < .001) and education (OR, 0.61; P = .02).CONCLUSION:Addressing identified barriers, including medication affordability and patient counseling, should be included in Pakistan's national policy on noncommunicable disease.

OBJECTIVE:To compile a comprehensive national cancer registry report of Pakistan by merging and analysing cancer registration data received from major functional cancer registries in various parts of Pakistan.STUDY DESIGN:Observational study. Place and Duration of the Study: Health Research Institute (HRI), National Institutes of Health (NIH), Islamabad, from 2015-2019.METHODOLOGY:Data from major cancer registries which included 'Punjab Cancer Registry (PCR), 'Karachi Cancer Registry (KCR)', 'Pakistan Atomic Energy Commission (PAEC) Cancer Registry', Armed Forces Institute of Pathology (AFIP) Cancer Registry, Nishtar Medical University Hospital Multan (NMH), and Shifa International Hospital, Islamabad (SIH) registries were pooled, cleared, and analysed at HRI.RESULTS:A total of 269,707 cancer cases were analysed. Gender-wise 46.7% were males and 53.61% were females. As per province-wise distribution, 45.13% of cases were from Punjab, 26.83% from Sindh, 16.46% from Khyber Pakhtunkhwa (KP), and 3.52% from Baluchistan. Both genders combined, 'breast cancer' 57633 (21.4%) was the most common cancer. In males, the top-5 cancers in order of frequency/percenatages were 'oral' 14477 (11.6%), 'liver' 8398 (6.73%), colorectal 8024 (6.43%), 'lung' 7547 (6.05%) and 'prostate' 7322 (5.87% cancers). In females, causes of the top-5-cancers included 'breast' 56250 (38.8%), 'ovary' 8823 (6.09%), 'oral' 7195 (4.97%), 'cervix' 6043 (4.17%), and 'colorectal' 4860 (3.36%) cancers. In children 'Leukemia' 1626 (14.50%) and in adolescents 'Bone' 880 (14%) were the leading malignancies.CONCLUSION:Breast cancer is the most common cancer in females touching epidemic proportions while 'oral cancer' which is the leading cancer in males ranks third in frequency in females. Like 'oral cancer' which shows a strong correlation with chewing, other common cancers in Pakistan including liver cancer, lung cancer, and cervical cancer are also largely preventable as showed a strong correlation with hepatitis B and C, smoking, and high-risk human papillomavirus.KEY WORDS:National Cancer Registry, Health Research Institute - NIH, Islamabad, Pakistan.

OBJECTIVE:To assess immediate outcome and complications of Amplatzer septal occluder percutaneous device for closure of secundum atrial septal defect in adults, and to determine regression in right ventricular size, reduced pulmonary arterial systolic pressure and incidence of device embolization at follow-up.METHODS:The single-cohort, ambi-directional, observational study was conducted at the Tabba Heart Institute, Karachi, from January 2013 to July 2018, and comprised patients admitted consecutively for percutaneous atrial septal defect closure. Pre-closure trans-oesophageal echocardiogram was performed in all cases to ensure adequacy of defect margins necessary for device stability. Immediate procedure success and complications were determined by trans-oesophageal echocardiogram, while transthoracic echo was done on follow-up. Data was analysed using SPSS 21.RESULTS:Of the 64 patients, 41(71.9%) were females. The overall mean age was 36.6±14 years. Median size of atrial septal defect was 21mm (interquartile range: 17-26mm). Immediate success was observed in 59(92.2%) patients, and there were 5(8%) acute device embolization events. Small residual atrial septal defect was found in 4(6.3%) cases. On 20-month follow-up, 54(84.4%) patients showed improved symptoms. Repeat transthoracic echo was performed in 39(60.1%) cases, and there were no late embolic events or residual atrial septal defect. Right ventricular size normalized in 34(89.5%) cases, mean pulmonary arterial systolic pressure reduced significantly compared to pre-closure measurement (p<0.001).CONCLUSIONS:Percutaneous atrial septal defect closure was found to be safe and effective in adults with secundum atrial septal defect. Timely closure resulted in improved symptoms, right ventricular remodelling and reduced pulmonary arterial systolic pressure at intermediate-term follow-up.

There is a scarcity of data on gender differences in outcomes during and after percutaneous coronary intervention (PCI) in the South Asian population. We assessed the gender differences in in-hospital mortality and complications in patients who underwent PCI. We conducted a cross-sectional study of 15,106 patients from the CROP (Cardiac Registry of Pakistan) CathPCI database. Logistic regression was used to determine factors associated with in-hospital mortality (primary outcome), access site hematoma, and bleeding complications. Approximately 19.6% were women. Women were older (mean age = 57.3 vs 54.4 years) and had a higher prevalence of diabetes (49.3% vs 32.6%), hypertension (72.8% vs 56.4%), peripheral arterial disease (1.5% vs 1%), and cerebrovascular accident (1.2% vs 0.8%) than men (p <0.05).Unadjusted in-hospital mortality was higher in women than in men (odds ratio [OR]: 1.6, 95% confidence interval [CI] 1.1 to 2.2); however, after adjusting for age, hypertension, diabetes, history of cerebrovascular accident, and ST-elevation myocardial infarction at presentation in the multiple logistic regression model, in-hospital mortality was comparable between men and women (adjusted OR [AOR] 1.2, 95% CI 0.8 to 1.7). The results remained consistent after propensity score matching of 5,904 patients (2,952 in each group, OR 1.3, 95% CI 0.9 to 2.0 for in-hospital mortality). Bleeding complications (1.2% vs 0.4%, AOR 2.6, 95% CI 1.4 to 4.5) and access site hematoma (2% vs 0.6%, AOR 2.8, 95% CI 1.8 to 4.5) were higher in women than in men. In conclusion, the incidence of in-hospital mortality was higher for women versus men, but adjusted risks were similar, likely driven by a greater co-morbidity burden among women.

According to the results of our examination, patients with OSAS have a more frequent development of hyperuricemia. Respectively, OSAS, adjusted for BMI, can be considered as an independent adverse risk factor for the development of cardiovascular events. Timely detection of OSAS will allow to start specialized treatment on time, improve the cardiovascular prognosis of this group of patients and, thus, reduce overall health care costs.

Background: The study aimed to describe the procedures implemented by medical colleges in Pakistan to assure quality in their assessment system. Method: A qualitative study was conducted from March 2015-December 2017 in medical colleges of Pakistan using grounded theory design. The medical colleges were selected by using non-probability convenient sampling technique. Out of the total 93 PMDC (Pakistan Medical and Dental Council) recognized medical colleges, 49 were selected from all four provinces of Pakistan as well as Azad Kashmir. An open-ended questionnaire was filled by one faculty member from each participating medical college after obtaining informed consent. Data was analyzed using SPSS version 21 (IBM). Results: Majority participants appreciated their institution’s assessment policy and wished improvement in terms of comparability to national organization’s assessment systems. For about 1/3rd of participants developing standardized tools, their grading (e.g. SEQs), and faculty’s unwillingness to devote time for quality MCQ were the challenges. Recommendations by > 1/3rd to overcome barriers included one assessment per year, improvement in teaching methods, standardized assessment, and structured viva exams. In >1/2 institutions no audit of assessment process was conducted. Around 1/3rd confirmed audit was an irregular unplanned activity and no report published. Around 1/4th of participants highlighted that a formal audit report stemmed in improving teaching & examination methods. Conclusions: Overall Quality Assurance (QA) procedures in assessment system in Pakistan were poorly implemented. Lack of QA and Monitoring & Evaluation (M&E), feedback mechanism, benchmarks for assessors, and formal auditing was noted. Student’s involvement, & semester system was recommended.

Publishing houses can play vital role in the mindset of readers of any society. Lahore, Rawalpindi, Faisalabad and Karachi became the hubs of the publishing industry after partition. These cities of Pakistan have rich history of publishing houses. These publishing houses played very important part in the state of mind of Pakistani readers. The objective of this research study was to make an appraisal of the trends of publishing in the field of Urdu Language in two decades of 21st century in Pakistan. To achieve these goals a mixed mode of research was used. Result reveals that the ratio of male writers recorded high in all subject areas i.e Poetry, Novel, Short story. The ratio of publications from Lahore city is high, followed by Karachi. Results shows that Al-Quresh Publishers, Lahore is at top of the list. Sang-e-Meel, Lahore is at second position followed by Oxford University Press. High ratio published material belong to Urdu poetry. There is a dire need to improve the Book trade and Publishing culture in Pakistan. Government should encourage publishers for reprint of classical Urdu publications.

Background: The slums are illegal settlements and are always left out in health surveys. However, studies around the world show that substance or drug abuse is higher among slum dwellers and may have different patterns and determinants which need to be studied in order to frame targeted programs and policies. The present study was aimed at estimating the magnitude as well as determinants of substance/drug abuse among slum dwellers in Islamabad, the capital city of Pakistan. Methodology: This community-based cross-sectional study was conducted among the residents of slums/nomadic settlements of Islamabad. A total of 207 statistically calculated sample size comprised of adults from both genders aged 15 years and above, consenting to participate from the randomly selected 9 clusters in Islamabad was needed for the study. From each cluster, 23 households, and from each household one individual was randomly selected for estimating the prevalence. All those who were abusing substances were counted as cases and others as controls for case-control analysis. A structured questionnaire was used to gather information on demographics, trends, types of substances abused, risk factors for getting engaged in substance abuse, whether they had tried to quit at any stage and what difficulties they faced when trying to quit. Results were entered and analyzed using Epi-info version 7.2. Results: A total of 204 participants were enrolled in this study. Among these 68 (33%) were substance or drug abusers. For the case-control study, substance/drug users were considered as cases 68 and rest as controls. Bivariate analysis of the risk factors indicated that easy of availability of drugs in slum areas (OR: 20.3, p= 0.000); exposure to tobacco smoking (OR: 8.8, p= 0.000); and being a working child (OR: 6.0, p= 0.000) were the strong predictors of high substance abuse. Education (OR: 0.2, p= 0.000) and living with own parents during childhood (OR: 0.7 p= 0.2) had protective effects against substance abuse. Conclusion and Implications for Translation: The study concludes that the following were the determinants of substance/drug abuse among the slum dwellers in the study: easy availability due to unregulated sales of drugs, high rate of tobacco consumption, poverty, low level of literacy, and being a working-child. Specific policies and plans focused on law enforcement for curbing the illegal drug sales and reduction of child labor along with the provision of education should be devised and implemented to help these neglected communities and modify the determinants. Key words: • Substance abuse • Drug abuse • Slum dwellers • Case-control • Islamabad • Pakistan Copyright © 2019 Faiza et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

OBJECTIVE:Prevalence of tobacco consumption is increasing including both smoked and smokeless tobacco. The objective of this paper is to highlight the prevalence of smokeless tobacco use, its demographic trends as well as socioeconomic determinants based on Global Adult Tobacco Survey 2014 (GATS) -Pakistan.METHODS:Secondary analysis of GATS data was done which was a nationally representative survey, conducted among non-institutionalized males and females aged 15 years and above. The survey included a total of 9,856 households which were selected using multistage stratified cluster sampling technique.RESULTS:Secondary analysis of GATS data revealed that 8.6% of the Pakistani population was current users of smokeless tobacco; among them, 8.0% were daily users and 0.6% were less than daily users. Prevalence of SLT use was higher in males (13.7%) compared to females (3.9%) (p = 0.000). Mean age of male users was 39.96±14.43 years and of females was 47.71±16.21 (p=0.000). Males (3.959 95% CI = 3.291-4.764) and respondents with primary or less education (2.216 95%CI = 1.841-2.668) were at higher odds of SLT use prevalence. Among daily users, Naswar was the preferred (71.8%) SLT product in males, compared to females (p = 0.000). Whereas, in females, use of Paan with tobacco (26.4%) (P = 0.000) and Naas (20.9%) (P = 0.000) was more common compared to males. Among SLT users, 71.1% participants used to spend 1-100 Rs (0.0095-0.95USD) per week on purchase of SLT products. However 28.9% were spending more than one dollar on the purchase of SLT products including 19.1% who were spending Rs 101-200 (0.96-1.9USD) followed by 7.2% spending Rs 201-300 (1.91-2.85 USD) and 2.6% spending Rs. >300 (>2.85 USD).CONCLUSIONS:Males and less educated individuals should be targeted with behavioral interventions for control of SLT use. Males started SLT use at an earlier age compared to females which can result in premature morbidity and mortality in males. SLT products are cheaper compared to cigarettes, therefore, taxes need to be levied on SLT products.

OBJECTIVE:To compare the findings of Global adult tobacco surveys (GATS) conducted in SAARC Countries.METHODS:The national representative data from Pakistan, India, and Bangladesh was used as GATS was done in these three countries of SAARC. The key variables were selected where information was consistently taken like current smokers, smokeless tobacco users, exposure to second-hand smoke, advise by health care provider to quit, monthly expenditure and noticing of health warning label and other information related to daily tobacco users (smoke, smokeless) mean age of initiation and mean number of cigarettes consumed per day were also collected. Chi-square test was applied and p-value was considered significant at <0.05.RESULTS:Overall tobacco consumption was significantly high (43.3%) in Bangladesh (Pakistan 19.1% and India 34.6%). Similarly, current smokers were significantly more in Bangladesh 23% (India 14% and Pakistan 12%) and smokeless tobacco was significantly more in Bangladesh 27.2% (India 25.9% and Pakistan 7.7%). Exposure to second-hand smoke at work was 69.1% in Pakistan (63% in Bangladesh and 29.9% in India). Monthly expenditure on cigarettes was also high in Pakistan 7.51 USD (India 6.26 USD and Bangladesh 4.57USD). Mean age of initiation was 18.8 years in Bangladesh, (17.8 India and 18.7 Pakistan). Mean number of cigarettes consumed was significantly high in Pakistan i.e. 13.6 (6.2 in India and 5.1 Bangladesh).CONCLUSIONS:All the three South Asian countries have a high prevalence of tobacco consumption. Tobacco use was high in Bangladesh but smokeless tobacco among males was high in India and mean number of cigarettes daily was high in Pakistan.

OBJECTIVE:An in-depth analysis of GATS 2014 is performed to study the various demographic determinants of smoked tobacco consumption among Pakistani adults. METHODS:The Global Adult Tobacco Survey (GATS) is a standardized surveillance mechanism regarding monitoring of tobacco consumption globally, that uses three stage cluster random sampling technique to have a representative data. We performed the complex data set analysis using SPSS V 15. The associations were determined by carrying out univariate analysis, and determining chi squares for categorical variables. RESULTS:Overall current smoking prevalence was found to be 12.4%. The univariate analysis revealed male gender (OR: 14.1 CI= 11.2-17.7, p value 0.000), little or no education (OR: 1.4 CI=1.2-1.6, p-value 0.000), living in urban areas (OR: 0.7 CI= 0.6-0.8, p-value 0.000) and avoiding smoking attempts in young age till 25 years (OR: 0.2 CI= 0.1-0.2, p value 0.000) were determinants. Assosiation of demographic determinants with cessation behaviour showed that the health concern was the primary reason to ever stop smoking among both urban rural dwellers, educated and uneducated and respondents aged 25 years and above. Educational status, age of respondent and residence had almost no significant effect on cessation behaviour of smoked tobacco users. CONCLUSIONS:Males having low education and living in rural area puts an adult Pakistani at high risk of becoming the user of smoked tobacco. Health education involving primary health care providers particularly focusing on rural areas will reduce the prevalence of smoking.

OBJECTIVE:About one-third of the world population is exposed to second hand smoke (SHS) with estimated 600,000 annual deaths. The objective of this article is to determine the exposure of adult Pakistani population to SHS and its association with different demographic variables based on data of Global Adult Tobacco Survey (GATS) conducted in 2014 in Pakistan.METHODS:Secondary analysis of Global Adult Tobacco Survey (GATS) data was done which is a global standard used for systematically monitoring use of both smoked and smokeless tobacco products. GATS Pakistan was a nationally representative survey, conducted in all four provinces among adult males and females aged15 years and above. Using multistage stratified cluster sampling technique a total of 9,856 households were selected and finally 7,831 individuals were enrolled.RESULTS:At homes around 43.3% individuals were exposed to SHS. Univariate analysis revealed that overall males (Odds Ratio, OR: 1.17 CI: 1.04-1.30, p=0.006) and less educated (OR: 1.30, CI: 1.16-1.46, p=0.000) group were at higher odds of being exposed to SHS at homes. Over all exposure to second hand smoke at home was also significantly high among urban residents (p = 0.000). Among nonsmokers age group 15 -35 years (odds ratio, 1.24 CI:1.09-1.04, P=0.01) and less educated group (OR 1.24, CI: 1.09-1.40, p=0.001) were at higher odds of being exposed to SHS at home At indoor workplaces, overall 69.1% and among non-smokers, 65.3% individuals were exposed to SHS. Univariate analysis has shown that less educated group (OR: 1.525, CI: 1.012-2.298, p=0.043) was at higher odds of being exposed to SHS at indoor workplaces. Among various public places exposure of participants to SHS was highest (86%) at restaurants, followed by public transport (74%), marriage halls (65%), universities (46%), health care facilities (35%) and least at schools (20%)..CONCLUSIONS:Less educated males were more exposed to second-hand smoke both at work places and public places; therefore to start with interventions, work places and public places should be a priority as at home results could be confounded by self-smoking as well.