Background: Low-and middle-income countries (LMICs) face increasing tobacco-related deaths. India is second in global tobacco use, with 29% adult users. Logistical challenges with in-person training in LMICs limit scale-up of tobacco control evidence-based interventions (EBIs). The Tobacco Free Teachers-Tobacco Free Society (TFT-TFS) program was previously shown to help teachers quit tobacco and schools adopt tobacco control policies. We are comparing smartphone-based training to in-person training to scale up the TFT-TFS program. Methods: Hybrid III cluster-randomized comparative effectiveness trial, involving 200 high schools and high secondary schools in Madhya Pradesh, India. To implement the TFT-TFS program, researchers randomly assigned schools to either smartphone-based (n=110 schools) or in-person (n=90 schools) training arms. Trained teachers from both arms implement the program in their respective schools. We will examine differences in program implementation, reach, and effectiveness between schools from the two arms. Post-implementation mixed-methods will employ the consolidated framework for implementation research (CFIR) to identify contextual factors influencing implementation. Conclusions: This study will scientifically and economically evaluate smartphone-based training to expand the use of EBIs for tobacco control in LMICs. Analyzing the contextual influences on TFT-TFS use in each training program will allow this work to create actionable guidance for education departments and groups involved in implementing smartphone-based training. These findings will help the CFIR strengthen its evidence on how to implement tobacco control EBIs successfully in low-resource environments. Trial Registration: This study is registered at ClinicalTrials.gov ID: NCT05500235.

INTRODUCTION/OBJECTIVE:E-cigarette use poses an additional risk for individuals who are not cigarette smokers, especially adolescents. The marketing tactics of the industry have substantially increased the prevalence of e-cigarettes, use among adolescents. India banned e-cigarette in September 2019 that has been criticized by interested groups.  We investigated that among adults and adolescents, who are more aware and using e-cigarette more?METHODS:The data were taken from a population-based representative household survey conducted in Mumbai and Kolkata in the year 2019-2020.  A household was enrolled if it had a 12-14 year old adolescent living in it and both adolescent and adult caregivers agreed to participate in the survey. The data from 944 adolescents out of 15,436 enumerated in Mumbai and 1038 out of 24,284 enumerated in Kolkata and their caregivers were analyzed for awareness and ever use of e-cigarettes.  Result: The awareness of e-cigarettes among 12-14 year olds in Mumbai was 15.5%, almost identical among boys and girls whereas is in Kolkata it was 11.2%. In contrast, among the adolescents' adult caregivers in Mumbai, the awareness was low, 3.9% and in Kolkata, 4.6%. Overall awareness was significantly higher among adolescents than among caregivers, especially among adolescent girls than among female caregivers in both cities.CONCLUSION:The awareness and the use of e-cigarette were very little and the messages from the e-cigarette industry seem to be targeted more towards adolescents than adults.  The ban on an e-cigarette in India has helped in prevented the marketing of ENDS to adolescents.

Research on family functioning within given cultural contexts is needed. This study aims to describe salient dimensions of family functioning in two urban contexts in India and to examine differences in family functioning by sociodemographic groups. We measured differences in family functioning using cross-sectional survey questionnaire data collected from 13 to 15-year-old adolescents and one of their parents/primary caregivers in Mumbai (n = 843) and Kolkata (n = 913) during 2019-2020. We drew a multi-stage sample representative of neighborhoods and households in both cities. We assessed a multi-dimensional family functioning latent factor that included parent-reported measures (parent-adolescent communication, family cohesion, and parent monitoring of peers) and adolescent-reported measures (parent support, family cohesion, and parent supervision). Our results support an overall measure of family functioning manifested by multiple dimensions for parent- and adolescent-reported data. Families with male adolescents had worse adolescent-reported family functioning in Mumbai and parent-reported family functioning in Kolkata. Higher socioeconomic status was associated with better parent-reported family functioning in both cities and better adolescent-reported family functioning in Kolkata. Muslim religious identification in Kolkata and the Hindi native language in both cities were associated with better adolescent-reported family functioning. Our findings indicate heterogeneity in family functioning across demographic and social-cultural groups within the two urban contexts of India. This study may inform the development of culturally congruent prevention interventions for families with adolescents in India.

Background Tobacco-Free Teachers, Tobacco-Free Society (TFT-TFS) is an evidence-based intervention that promotes tobacco use cessation among teachers and tobacco control policies among schools in India. This study tested an implementation model to build Bihar Department of Education (DOE) capacity to support and deliver TFT-TFS within schools, leveraging DOE training infrastructure. Method We used a training-of-trainers (TOT) “cascade” implementation strategy to embed the TFT-TFS program into the Bihar DOE infrastructure. We trained 46 Cluster Coordinators to train and support Headmasters to implement TFT-TFS in their schools over one academic year. We selected three school districts, representing approximately 46 clusters and 219 schools. We used the RE-AIM framework to assess program adoption (Headmaster participation in at least one of six TFT-TFS trainings), implementation (of four core program components), and reach (teachers' participation in three or more group discussions). Using a non-inferiority design, we hypothesized that program adoption, implementation, and reach would not be inferior to the high standards demonstrated when TFT-TFS was originally tested in the Bihar School Teachers Study. We used self-reported checklists to measure outcomes and SPSS Version 25 to analyze data. Results For adoption, 94% of Headmasters attended the first training, although participation declined by the sixth training. Among the 112 schools out of 219 with complete Headmaster checklist data, all met our minimum criteria for implementing TFT-TFS. Over 99% of schools posted a school tobacco control policy and distributed quit booklets. However, only 69% of schools met our criteria for program reach. Conclusions This study outlines the processes for taking a tobacco control intervention to scale and implementing it through the Bihar DOE infrastructure. These findings provide a foundation for other Indian states and low- and middle-income countries to implement tobacco control and other health programs for schoolteachers. Trial registration NCT05346991. Plain Language Summary Each year in India, more than 1.2 million people die from tobacco-related causes, and India has the world's highest oral cancer burden. The world needs more evidence on how to bring cost-effective tobacco control interventions to scale, especially in low- and middle-income countries (LMICs). To address this gap, from 2017 to 2021, we examined the process of scaling up Tobacco-Free Teachers, Tobacco-Free Society (TFT-TFS), an evidence-based intervention promoting tobacco use cessation among teachers and tobacco control policies in schools. Our study tested an implementation model aimed at building the Bihar State Department of Education (DOE) capacity to support and deliver TFT-TFS. We used a training-of-trainers model to embed TFT-TFS into Bihar DOE infrastructure, training 46 Cluster Coordinators to in turn train and support Headmasters to implement TFT-TFS over one academic year. We hypothesized that program adoption, implementation, and reach would not be inferior to the high standards demonstrated when we originally tested TFT-TFS through the Bihar School Teachers Study (2013–2017). For adoption, 94% of Headmasters attended the first training, although participation declined by the sixth training. Of 112 schools (out of 219 with complete Headmaster checklist data), all met our minimum criteria for implementing TFT-TFS. Over 99% of schools posted a school tobacco control policy and distributed quit booklets. However, only 69% of schools met our criteria for program reach. Study findings offer other Indian states and LMICs lessons to implement tobacco control and other health programs for schoolteachers within educational systems.

OBJECTIVES:To study the MPOWER measures over time (GATS-1 vs GATS-2) and their effects on tobacco control indicators in India.STUDY DESIGN AND METHODS:The study used a cross-sectional design to compare the common questions identified from GATS-1 and GATS-2. Odds ratios for various MPOWER measures were estimated using a multivariate logistic regression model.RESULTS:Compared with GATS-1, the current any tobacco use was reduced by 32% in females and 17% in males in GATS-2 (M-measures). The P-measures have reduced across the survey periods. Under O-measures, compared with mixed users, only the male smokeless tobacco (SLT) users reported receiving more advice from a doctor to quit and reported trying more to stop SLT use. Compared with never users (W-measures), the health warnings were noticed on SLT products more by past users, smokers (males), and SLT users, while it was noticed on cigarette packages more by male past users and smokers. Promotion (E-measures) of cigarette and bidi was reported more by smokers (including mixed users), and promotion of SLT product was reported more by smokers (including mixed users) and male SLT users than by never users.CONCLUSION:Overall, MPOWER measures have shown improvement, with most changes highly reported by the never users and past users than by the current tobacco users. Stringent methods for the enforcement of MPOWER measures to reach all forms of tobacco users and integration of the National Tobacco Control Programme with other national health programs are imperative for highest achievements. Also, specific targeted strategies for the effective control of SLT use are highly recommended to be included in the MPOWER package.

A randomised control trial was conducted among school teachers in Bihar, India for upscaling a tested, evidence-based tobacco intervention using train-the-trainer model. Six blocks in three districts were selected and randomised into intervention and control blocks. Cluster coordinators in intervention blocks were given training in the details of intervention. Cluster coordinators routinely train headmasters and they were asked to include intervention training in their routine. Except for the training material, no additional resources were provided to cluster coordinators and headmasters. Headmasters implemented the intervention along with the teachers in the school. Post-intervention random sample of 70 schools out of 219 schools from intervention blocks and 70 schools out of 224 schools in control blocks were surveyed. The survey was self-administered among 429 school teachers in intervention schools and 331 among control schools. For all 140 headmasters, the survey was interviewer administered. Almost all headmasters in intervention schools had attended the training and had involved teachers in the intervention program. Odds ratios for carrying out the recommended activities in intervention schools compared to control schools were very high and significant. In addition, intervention schools also conducted activities such as including intervention messages in classroom teaching and conveying them to parents, activities that were not directly recommended in intervention program. Thus, this train-the-trainer model demonstrated that it is possible to upscale the intervention programs successfully with the resources within the system.

BackgroundNeighbourhood tobacco retail access may influence adolescent tobacco use. In India, we examined the association between neighbourhood tobacco retail access and cognitive risks for tobacco use during early adolescence.MethodsIn 2019–2020, a population-based sample (n=1759) of adolescents aged 13–15 years was surveyed from 52 neighbourhoods in Mumbai and Kolkata. Neighbourhood tobacco retail access was measured as the frequency of visits to tobacco retailers, mapped tobacco retailer density and perceived tobacco retailer density. We estimated associations between neighbourhood tobacco retail access and cognitive risks for tobacco use (perceived ease of access to tobacco, perceived peer tobacco use and intention to use tobacco).ResultsThere was high neighbourhood tobacco retail access. Tobacco retailer density was higher in lower income neighbourhoods (p<0.001). Adolescent frequency of tobacco retailer visits was positively associated with cognitive tobacco use risks. Mapped tobacco retailer density was associated with perceived ease of access in Kolkata but not in Mumbai, and it was not associated with perceived peer tobacco use nor intention. Perceived tobacco retailer density was associated with perceived ease of access and perceived peer use, but not with intention. In Kolkata, higher perceived retailer density and frequency of tobacco retailer visits were negatively associated with perceived ease of access.ConclusionsEfforts to reduce neighbourhood tobacco retail access in India may reduce cognitive tobacco use risk factors in young adolescents. The frequency of tobacco retailer visits and perceived tobacco retailer density increased cognitive risks, though there were some exceptions in Kolkata that further research may explain.

Background and Objectives: The prevalence of cardiovascular diseases (CVDs) poses significant clinical and public health challenges across the world. This study aimed to study the metabolic risk factors and the association with blood pressure alteration. Materials and Methods: This was a cross-sectional study conducted between 2017 and 2018 among 284 male university students in Eastern province, Saudi Arabia. The obesity and cardiovascular measurements were taken using standardized instruments, including blood pressure (BP), mean arterial pressure, body mass index (BMI), body adiposity index (BAI), waist circumference (WC), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), body fat percentage (BFP), and basal metabolic rate (BMR). Statistical Analysis: Blood pressure was classified according to the United States of America, Sixth Joint National committee (JNC-VI) guidelines. The mean and standard error were calculated for each hypertension group variable. Logistic regression was applied to predict associations. Results: The prevalence of hypertension in the present study was 61.6%., and that of overweight and obesity was 16.5% and 34.9%, respectively. The cut-off values of BMI and WC were 22.23 and 75.24, respectively. Conclusions: The results demonstrated that BMI, WC, WHR, and WHtR significantly predict hypertension and that WC has a greater discrimination capacity than other measures. The findings also emphasize the importance of cardiovascular risk screening for young adults to detect any alterations in blood pressure and thus identify the population that is vulnerable to CVDs at an early stage. The findings highlight the need for health and university policymakers to adopt measures to monitor and control hypertension and obesity at the university level.

India despite progress in tobacco cessation delivery in government sector has lagged in private health sector. Adopting a two-fold approach of intensive intervention-based counseling with (or without) pharmacotherapy; and prescheduled proactive follow-ups over the subsequent year, this study reports 337 tobacco patients, each followed for a period of 1 year. It observed a quit rate (QR) of 40.9% for total abstinence at 1 year but with a drop of 15.9% when patients were followed up, up to 6 months (49.6%) versus 6–12 months (34.7%). The pharmacotherapy did not benefit to whom it was prescribed (196 [58.2%] patients; QR: 34.7%) versus the rest to who it was either not prescribed or was declined (141 [41.8%] patients; QR 49.6%). Countrywide tobacco cessation clinics (TCCs) may be established in private sector hospitals, and the component of quitline methodology of making proactive calls may be integrated to improve QR in India.

Background: Despite specific national effort for over a decade, in published reports on tobacco cessation from India, the quit rate has ranged from 2.6% to 28.6%. One of their challenges has been an inability to follow-up all those treated comprehensively. Objective: It was to determine an optimum number of follow-up telephonic calls to be made proactively post the cessation treatment. Methods: This study was conducted for a period of one year w.e.f. 5th September 2017 at a Tobacco Cessation Clinic (TCC) of a private health sector tertiary care hospital to 296 patients currently using tobacco treated by counselling with/ without pharmacotherapy; and integration of the quitline methodology with follow ups at 3rd and 7th days, and thereafter at the end of 1st, 3rd, 6th and 12th months respectively, i.e., until 4th September 2019. Results: As per study protocol, the TTC could follow up 91.2% patients telephonically to achieve a quit rate of 42.9% while those who failed to quit and relapsed were 37.7% and 19.9% respectively. Staying on with the quit date set at the outset and adequacy of three follow-up calls have emerged as the statistically significant outcomes for p values of 0.000 and 0.001 respectively. Conclusion: Achieving a quit rate of 42.9% through the proactive follow-up calls reinforces its perceived utility in tobacco cessation. Making at least 3 follow-up calls after primary intervention (on 3rd, 7th and at 1 month) is recommended to achieve a satisfying outcome. For an optimal outcome, the study recommends follow-ups until 6 months. Keywords Tobacco, Cessation, Follow up, Telephonic calls, Quitline, Smoking, Smokeless tobacco

Background: The dual use of tobacco (smoked as well as smokeless tobacco products) is mostly to either circumvent ever-growing smoke-free environment or to obtain a higher dose of nicotine to satisfy its addiction. Material and Methods: This prospective, non-randomized study of 109 current dual tobacco users over 30 months (September 2017 to February 2020) from a TCC in a multi-specialty tertiary care hospital has focused to observe and report a correlation of the outcomes of the tobacco dependence treatment with critical features in the processsetting up of the quit date, addiction to nicotine and follow-up up to 1 year. Results: In this male dominated study (99.08%), 41 quitted successfully (36.7%; CI 28.1, 46.0) while 43 failed to quit (39.4%; CI30.6, 48.8) and 26 relapsed (23.9%; CI16.6, 32.5). The sole determinant to stay abstinent totally was their ability to stay quit through the follow-up of over 6 months. Conclusion: The new learning from this study on the dual users of tobacco in India is that to achieve a higher quit rate, there is need is to sustain follow-up for a longer duration among the successful quitters. Endorsing quitting over harms reduction, this study recommends a larger and elaborate multi-centre study in view of their smaller numbers vs. sole users of smoking or SLT.

BackgroundTobacco is the leading avertable cause of death in the world.Adolescents are the most vulnerable population to initiate the use of tobacco.Most adult users start tobacco use in their childhood or adolescence.The Global Youth Tobacco Survey (GYTS) was design to obtain information on tobacco use, exposure to tobacco smoke and other related indicators among adolescent.This study aims to compare the GYTS data between 2000 and 2015 for the state of Maharashtra in India. MethodsThe GYTS is a school-based two-stage cluster design survey of students aged 13-15 years.This was a self-administered crosssectional survey conducted in Maharashtra using standardized GYTS questionnaire.To record student survey responses, in 2000 optically readable answer sheets and in 2015 tablets were used.For statistical data analysis SPSS 20.0 was used. ResultsBetween 2000 and 2015 the prevalence of tobacco use reduced from 17% to 11% among boys and 14.5% to 8.5% among girls.Age of tobacco initiation has shifted from 11 years or younger (~70%) in 2000 to older than 11 years (~70%) in 2015.Proportion of students who received pocket money increased from 20.2% to 42.7% for boys and 18.7% to 33.8% for girls in 2015.Discussions about harmful effects of tobacco in schools and at home had reduced from 2000 to 2015.Distribution of free tobacco products decreased over the years, however sale of tobacco products to minors and sale around educational institutions continued. ConclusionPrevalence of overall tobacco use has decreased.Strengthening the existing Cigarettes and Other Tobacco Products Act (COTPA) laws and improving implementation and effective monitoring will not only reduce youth's tobacco use but might restrict future initiation among youths.Continuous tobacco education at home and at school will further strengthen the tobacco control efforts.

This study on systems approach in tobacco dependence treatment was done to (a) Assess the feasibility of tobacco treatment protocol (TTP), (b) Assess quit rate among those treated with TTP vs. no treatment and (c) Compare treatment outcome in Brief Intervention (BI) and Intensive Intervention (II) with or without pharmacotherapy. This one year study (2013), undertaken at a hospital at Jaipur, India identified currently tobacco-using patients. Those willing were assisted to quit through brief intervention (BI) or intensive treatment (II). All were followed-up telephonically for one year. The responders were categorized as successful quit, failed to quit and relapsed. This study enrolled 1264 patients out of 19657 (6.43%). In 43.4 per cent patients (549/1264) who consented for the treatment, the overall quit rate was 26.1 per cent (CI: 23.8 -28.6) whereas in those treated with BI and II were 54.2 per cent (CI: 49.7 -59.0) and 84.9 per cent (CI: 78.4 -92.0) respectively vs. zero quit rate in untreated. The use of pharmacotherapy improved overall quit rate by 14.6 per cent. The quit rates did not differ for the type of tobacco used. Since, this study could achieve its objective of implementing the systems approach in tobacco treatment protocol in a hospital-setting, it merits a replication.

Background & objectives: Beginning in 2012, all States in India eventually banned the sale of gutka. This study was conducted to investigate gutka vendors' knowledge on gutka ban, products covered under ban, penalties for non-compliance and action for enforcement by government agencies. Methods: Twenty vendors were interviewed, 10 each in Mumbai (Maharashtra) and Indore (Madhya Pradesh) during May - June, 2013, one year after ban was imposed. Interviewers used a standardized questionnaire to assess vendors' knowledge of gutka ban, their attitude towards it and compliance to it in practice. Results: All 20 vendors were aware that gutka sale was banned. However, despite ban, eight of the 10 vendors in Mumbai perceived sale of pan masala as legal. In Indore, all 10 vendors perceived sale of Indori Tambakoo, a local gutka variant, as legal. No vendor was sure about the quantum of fine applicable on being caught selling the banned product. Two vendors in Mumbai and nine in Indore admitted selling gutka. Five vendors in Mumbai and four in Indore supported an existing ban on gutka. Interpretation & conclusions: All vendors were aware of the ban on gutka and reason for it. Many vendors supported the ban. However, awareness of other products covered under ban and on fines in case of non-compliance was low. Law enforcement system needs to be intensified to implement ban. Notification of ban needs to be further strengthened and made unambiguous to explicitly include all smokeless tobacco products.

Background: Tobacco use, alcohol use and Socioeconomic status (SES) are all strongly associated with mortality.These risk factors however, are also strongly associated with each other.The effect of the interrelationship between these risk factors on mortality has not been examined in India.Objectives: To study tobacco and alcohol associated Hazard Ratios (HRs) stratified by SES.Methods: A cohort of 34,055 men (age>=45 years) was recruited through house visits and information collected through face-to-face interviews during 1994 to 1997.During 1999 to 2003, follow-up through repeat house visits was conducted and deaths were recorded.Education level was used as proxy for SES.Cox proportional hazards model provided HRs and 95% Confidence Intervals (CIs) for tobacco/alcohol associated mortality adjusted for alcohol/tobacco and other confounders.Additionally, HRs was stratified by SES for their individual (tobacco, alcohol use) and their joint effect on mortality.Results: For tobacco associated mortality, stratification by SES showed higher HRs for high SES bidi smokers (HR=2.01)compared to corresponding low SES bidi smokers (HR=1.41).For alcohol associated mortality, HRs were higher among high SES 'country/desi' drinkers (HR=1.56)compared to corresponding low SES counterpart (HR=1.31).After adjusting for alcohol exposure, the highest attenuation of HRs (>20%) for tobacco associated mortality was observed for deaths from tuberculosis and digestive system diseases (mainly liver diseases) among various forms of tobacco users.Conclusions: The examination of differences in mortality risks by SES, showing higher HRs among high SES bidi smokers and high SES 'country/desi' drinkers, have implications for public health policies.

Objectives: To explore the potential role of the work context associated with tobacco use patterns among manufacturing workers in India Methods: We used cross-sectional survey data from the Mumbai Worksite Tobacco Control Study. Workers from manufacturing worksites in the greater Mumbai region were surveyed from 20 worksites that were recruited between July 2012 and July 2013 on rolling basis for a randomized controlled trial. Results: A total of 6880 workers out of 7633 that employed in 20 manufacturing worksites were surveyed. Current tobacco use was higher among production (23.5%) than non-production (19.2%) workers. In contrast, past tobacco use was somewhat lower among production (6.2%) than non-production (8.4%) workers. Production workers who used smokeless tobacco were twice as likely to report their workplaces did not have a policy or rule prohibiting tobacco use as compared to smokers or non-tobacco users. The prevalence of past tobacco use - compared to current use - was associated with workers’ education, economic index and number of co-workers using tobacco. Conclusions: The current study underscores the important role of co-workers and worksite tobacco control policies (that cover both smoking and smokeless forms) to support reductions in tobacco use among manufacturing workers.

Background Underweight and severe and morbid obesity are associated with highly elevated risks of adverse health outcomes. We estimated trends in mean body-mass index (BMI), which characterises its population distribution, and in the prevalences of a complete set of BMI categories for adults in all countries.Methods We analysed, with use of a consistent protocol, population-based studies that had measured height and weight in adults aged 18 years and older. We applied a Bayesian hierarchical model to these data to estimate trends from 1975 to 2014 in mean BMI and in the prevalences of BMI categories (<18.5 kg/m(2) [underweight], 18.5 kg/m(2) to <20 kg/m(2), 20 kg/m(2) to <25 kg/m(2), 25 kg/m(2) to <30 kg/m(2), 30 kg/m(2) to <35 kg/m(2), 35 kg/m(2) to <40 kg/m(2), = 40 kg/m(2) [morbid obesity]), by sex in 200 countries and territories, organised in 21 regions. We calculated the posterior probability of meeting the target of halting by 2025 the rise in obesity at its 2010 levels, if post-2000 trends continue.Findings We used 1698 population-based data sources, with more than 19.2 million adult participants (9.9 million men and 9.3 million women) in 186 of 200 countries for which estimates were made. Global age-standardised mean BMI increased from 21.7 kg/m(2) (95% credible interval 21.3-22.1) in 1975 to 24.2 kg/m(2) (24.0-24.4) in 2014 in men, and from 22.1 kg/m(2) (21.7-22.5) in 1975 to 24.4 kg/m(2) (24.2-24.6) in 2014 in women. Regional mean BMIs in 2014 for men ranged from 21.4 kg/m(2) in central Africa and south Asia to 29.2 kg/m(2) (28.6-29.8) in Polynesia and Micronesia; for women the range was from 21.8 kg/m(2) (21.4-22.3) in south Asia to 32.2 kg/m(2) (31.5-32.8) in Polynesia and Micronesia. Over these four decades, age-standardised global prevalence of underweight decreased from 13.8% (10.5-17.4) to 8.8% (7.4-10.3) in men and from 14.6% (11.6-17.9) to 9.7% (8.3-11.1) in women. South Asia had the highest prevalence of underweight in 2014, 23.4% (17.8-29.2) in men and 24.0% (18.9-29.3) in women. Age-standardised prevalence of obesity increased from 3.2% (2.4-4.1) in 1975 to 10.8% (9.7-12.0) in 2014 in men, and from 6.4% (5.1-7.8) to 14.9% (13.6-16.1) in women. 2.3% (2.0-2.7) of the world's men and 5.0% (4.4-5.6) of women were severely obese (ie, have BMI = 35 kg/m(2)). Globally, prevalence of morbid obesity was 0.64% (0.46-0.86) in men and 1.6% (1.3-1.9) in women.Interpretation If post-2000 trends continue, the probability of meeting the global obesity target is virtually zero. Rather, if these trends continue, by 2025, global obesity prevalence will reach 18% in men and surpass 21% in women; severe obesity will surpass 6% in men and 9% in women. Nonetheless, underweight remains prevalent in the world's poorest regions, especially in south Asia. Copyright (C) NCD Risk Factor Collaboration. Open Access article distributed under the terms of CC BY.